Study on diagnosis and management strategies on heterotopic pregnancy: a retrospective study.

Heterotopic pregnancy (HP) is a rare but potentially life-threatening event with a high risk of maternal death, which also jeopardise the coexisting intrauterine pregnancy (IUP), thus an early accurate diagnosis and prompt treatment can decrease adverse complications. We aimed to explore the early predictors for pregnancy outcomes of HP. We reviewed patients with HP following assisted reproductive technology in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and clinical features were analysed by logistic regression. We found that 29 patients (72.5%) of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Eighteen patients in the surgery group had live births, three of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity than those without (16.7% vs. 90.0%, p < .001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as favourable independent predictor of live birth (p < .001). Therefore, early diagnosis and prompt surgical intervention are recommended to prevent the development of HP.Impact of statementWhat is already known on this subject? Heterotopic pregnancy (HP) has long been thought to be a rare but potentially life-threatening event with a high risk of complications. The early diagnosis of HP is challenging due to the co-existence of a viable intrauterine pregnancy (IUP) and the absence of typical clinical symptoms.What do the results of this study add? This stduy showed that symptoms combined with routine transvaginal ultrasonography (TVS) scans reduce the rates of misdiagnosis of HP and prompt surgical intervention after diagnosis may minimise the incidence of miscarriage of the IUP.What are the implications of these findings for clinical practice and/or further research? An IUP with cardiac activity at HP diagnosis is a predictor of a favourable prognosis of HP, and laparoscopy under general anaesthesia is effective and safe during the first trimester of pregnancy. Awareness, assessment and early interventions in view of symptoms combined with routine TVS is recommended to reduce the risk of miscarriage and ensure a favourable live birth rate.

Ectopic pregnancy: a single-center experience over ten years.

PURPOSE: The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality. METHODS: This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, ß-human chorionic gonadotropin (ß-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA). RESULTS: The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10- 5) that was diagnosed in the 7th gestational week. The only association found was between the ß-HCG level and LOS, with a linear regression ß coefficient of 0.01 and a P-value of 0.04. CONCLUSION: EP is a relatively common condition affecting approximately 1% of all pregnancies. ß-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

Uterine Artery Embolization in the Twentieth Week of Pregnancy in Abnormally Invasive Placenta with Live Birth.

An abnormally invasive placenta is an increasing and potentially life-threatening pregnancy complication. The case presented herein is a heterotopic dichorial pregnancy with implantation of 1 placenta within the isthmocervical area, which caused vaginal bleeding during the 20th week of pregnancy, requiring a blood transfusion. To stop the bleeding, a bilateral embolization of the cervical branches of the uterine arteries was performed. The embolization was well tolerated and resulted in the abrupt and lasting cessation of bleeding for more than 10 weeks, resulting in the live birth of 1 child.

Successful heterotopic pregnancy with prior radical trachelectomy after transabdominal cervico isthimic cerclage with methotrexate treatment.

Heterotopic pregnancy with cervical incompetence is very uncommon. And yet there is no definite treatment for cervical incompetence occurring after radical trachelectomy. We are reporting a rare and novel case of a following in vitro fertilization combined intrauterine pregnancy and interstitial pregnancy which was successfully treated with maintenance of the pregnancy to term.

Heterotopic pregnancy: Simultaneous viable and nonviable pregnancies.

Heterotopic pregnancy occurs when a patient has simultaneous intrauterine and ectopic pregnancies. Rates of heterotopic pregnancy have been rising with increased availability and access to in vitro fertilization and other advanced fertility technologies. Symptoms of heterotopic pregnancy are nonspecific, such as vague abdominal pain, so transvaginal ultrasound is a crucial part of the diagnostic process. Laparoscopy is the most commonly performed treatment of the ectopic pregnancy; other options include localized injections of methotrexate and/or potassium chloride. Following definitive termination of the ectopic pregnancy, many patients will successfully deliver the intrauterine pregnancy at term. Early identification of heterotopic pregnancy can reduce maternal morbidity and mortality.

The effect of local aspiration and methotrexate injection on live interstitial pregnancy coexisting with live intrauterine pregnancy after assisted reproductive technology.

AIM: To share the experience of local aspiration and instillation of methotrexate (MTX) to selective reduction of live interstitial pregnancy and to evaluate its clinical effect and the outcome of intrauterine pregnancy. METHODS: Twelve patients with heterotopic interstitial pregnancy were enrolled at Women's Hospital, Zhejiang University School of Medicine, from 2006 to 2017. All the pregnancies were derived from assisted reproductive technology (ART). The transvaginal aspiration to interstitial pregnancy sac and local instillation of MTX (range from 12.5 to 30 mg) were performed for the patients under ultrasound-guide. The prognosis and pregnancy outcomes were followed up. RESULTS: No severe side effects of medical treatment were observed in all patients. Three cases underwent subsequent laparotomy cornual resection, and no perioperative complications were found in these three patients. Twelve patients gave birth to 13 healthy infants without congenital anomalies. The average birth weight and gestational age was 2837 g (SD ± 605 g) and 36.8 weeks (SD ± 2.4 weeks). No growth anomalies and mental retardation were observed in live birth offspring. CONCLUSION: The transvaginal ultrasound-guided aspiration and injection of MTX might be a feasible alternative treatment for heterotopic interstitial pregnancy when vital signs of patients are stable.

[Management and pregnancy outcomes of heterotopic pregnancy].

Objective: To investigate the clinical features, diagnosis and treatments of heterotopic pregnancy (HP) and demonstrate the outcomes of HP after the surgical treatment of ectopic pregnancies. Methods: A retrospective analysis was performed on 144 cases of HP in Women's Hospital, School of Medicine, Zhejiang University from January 2003 to December 2016. Results: (1) Clinical features of HP:the average age of patients was (30.8±3.8) years old, body mass index (BMI) was (21.9±2.9) kg/m(2), and was diagnosed at (6.5±1.3) weeks gestational age. Four patients (2.8%) were naturally pregnant, 10 patients (6.9%) received ovulation induction, and 130 patients (90.3%) had received infertility treatments. Fifty-one patients (35.4%) had no clinical symptoms, and 93 patients (64.6%) had clinical symptoms included vaginal hemorrhage,abdominal pain and hemorrhagic shock caused by intraperitoneal hemorrhage. The location of ectopic pregnancy was most common in the fallopian tubes (59.0%, 85/144) and the interstitial part (33.3%,48/144) . (2) Ectopic pregnancy treatment of HP:thirteen patients underwent expectation treatment, and the remaining 131 cases underwent surgical treatment, including laparoscopy (n=56) , laprotomy (n=52) , and fetal reduction (n=23) . Among the 131 patients underwent surgery, intrauterine pregnancy were found inevitable abortion in 6 cases preoperatively. The total early abortion rate after surgery was 14.4% (18/125) ; the second operation rate was 3.1% (4/131) . (3) Intrauterine pregnancy outcome of HP: 120 intrauterine fetal were survival, the total live birth rate was 83.3% (120/144) .One hundred and seven intrauterine fetal were survival after operation and the live birth rate after operation was 85.6% (107/125) . Twenty-nine cases were premature delivery and the premature delivery rate was 24.2% (29/120) . There was no significant differences between tubal HP and interstitial HP group in the preterm birth rate [25.8% (16/62) vs 26.3% (10/38) ; χ(2)=0.003, P>0.05]. Cesarean section rate of delivery in interstitial HP group was significantly higher than that in tubal HP group [97.4% (37/38) vs 59.7% (37/62) ], and the difference was statistically significant (χ(2)=17.400, P<0.05) . Conclusions: The clinical manifestations of HP are diversified, combining of high risk factors, clinical symptoms and ultrasonography could improve the accuracy of diagnosis. Different method has been used to treat HP, such as laparoscopic or laparotomy and fetal reduction, and there are varying degrees of failure rate and postoperative abortion rate. We should consider carefully to adopt expectant management. Through individualized treatment, most HP could get good perinatal outcomes.

Successful pregnancy in a woman with uterine scarring by transverse fundal cesarean section.

There has been only one case to date of pregnancy outcome after fundal transverse cesarean section (FTC). We report a pregnancy established after FTC. The FTC was performed at gestational week (GW) 24 in this patient's first pregnancy, but the uterus was preserved. Magnetic resonance imaging studies performed four times in her second pregnancy consistently showed part of the uterine fundus in which the muscle layer was interrupted. Concern regarding spontaneous uterine rupture in the absence of labor pains prompted us to interrupt her pregnancy at GW 31(+5) , delivering a premature, but otherwise healthy female infant, weighing 1832 g. The infant required transient intratracheal intubation for respiratory distress syndrome (for less than 1 h), but had an otherwise uneventful clinical course. Two cases, including ours, suggest that successful pregnancy outcome is feasible at least in some women with uterine scarring due to FTC.

Successful full-term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management.

Heterotopic cesarean scar pregnancy (CSP) usually follows assisted reproductive technologies (ART) in women who have already delivered by cesarean section. It is extremely rare: thus far, there have been only 12 individual case reports. However, over the last 20 years, the rate of cesarean delivery has increased and ART have become more common; hence, heterotopic CSP will be more prevalent in the future. Currently available data suggest that the early selective termination of CSP by medical or surgical methods is the most reliable treatment in the hemodynamically stable heterotopic CSP women because of the serious complications of continuing the CSP. We present the first case report of heterotopic CSP in a spontaneous cycle with expectant management that resulted in full-term twin deliveries.

Management of cesarean heterotopic pregnancy with transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, and review of the literature.

Cesarean scar pregnancy is one of the rarest forms of ectopic pregnancy, located in the scar from a previous cesarean section. There are few reports of such pregnancies, and there is no consensus about the best management. Herein is reported a case of cesarean heterotopic pregnancy, diagnosed at 6 weeks' gestation and successfully treated via transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, with preservation of the intrauterine pregnancy.

Treatment of early heterotopic interstitial (cornual) gestation with subsequent delivery of an intrauterine pregnancy--case report.

We present the case of a 38-year-old woman who was treated for a heterotopic interstitial (cornual) pregnancy diagnosed at the 7th week of gestation. The intervention was performed via transvaginal ultrasound-guided aspiration and instillation of a hypertonic solution of sodium chloride into the cornual sac. The heterotopic comrnual pregnancy was successfully aborted, and the intrauterine pregnancy was successfully maintained with delivery of a healthy newborn.

Heterotopic cervical pregnancy after in-vitro fertilization - case report and literature review.

Heterotopic cervical pregnancy is an uncommon condition, with a rising incidence due to the increasing number of pregnancies resulting from in-vitro fertilization (IVF). Although it is associated with maternal-fetal complications, there is no consensus in the literature about the best approach for this condition. This study aims to report a case of cervical heterotopic gestation after IVF in which the intrauterine pregnancy was preserved, with spontaneous elimination of the cervical gestational sac after patient sedation and introduction of the vaginal speculum. In addition, we reviewed the literature on the subject, which demonstrated that most cases have a favorable outcome, especially after treatment with surgical excision of the cervical pregnancy. The growing body of evidence is still scarce to define the best treatment for this condition.

Complications of Assisted Reproductive Technology.

Although only accounting for a small percentage of infants born in the United States each year, assisted reproductive technology (ART) has become a more common means of conception since the first in vitro fertilization baby was born in 1978. An understanding of the ART process, medications, and complications is becoming essential for emergency medicine practice. Much of the surveillance data focuses on ART complications that are likely to be less relevant in the acute care setting, but ovarian hyperstimulation syndrome, ectopic pregnancy, and ovarian torsion are 3 diagnoses with high potential morbidity and mortality that emergency physicians should not miss.

Normal vaginal delivery at term after expectant management of heterotopic caesarean scar pregnancy: a case report.

BACKGROUND: Heterotopic pregnancy with a combination of a caesarean scar pregnancy and an intrauterine pregnancy is rare and has potentially life-threatening complications. CASE PRESENTATION: We describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. This is a report of the successful expectant management of a heterotopic scar pregnancy. The gestational sac implanted into the scar area was non-viable. The woman was treated expectantly and had a normal vaginal delivery at 37 weeks of gestation. CONCLUSION: Expectant management under close monitoring can be appropriate in small non-viable heterotopic caesarean scar pregnancies.

The risk factors of miscarriage and obstetrical outcomes of intrauterine normal pregnancy following heterotopic pregnancy management.

To investigate the clinical characteristics and risk factors for miscarriage of intrauterine normal pregnancy of patients with a heterotopic pregnancy (HP) after treatment.This was a retrospective study of medical records from CHA Bundang Medical Center. Sixty-four patients who were diagnosed with a HP between February 2006 and July 2017 were included in this study. All analyses were performed using SAS software, version 9.4 (SAS Institute, Inc., Cary, NC). P values < .05 were considered statistically significant.Forty-eight patients had tubal ectopic pregnancies (EP), 10 patients had cornual EPs, 1 patient had a cesarean section scar EP, 4 patients had an ovarian EP, and 1 patient had bilateral tubal EP. Among the 64 patients, 14.1% (9/64) miscarried before 10 weeks of gestation after management. Mean gestational age (GA) at treatment was 5.97 ±â€Š0.50 weeks and 6.80 ±â€Š1.04 weeks for miscarriage and nonmiscarriage group, respectively (P = .008). Significant differences were observed between 2 groups in terms of ultrasonographic features at the time HP was diagnosed (P = .040) Logistic regression models indicated that gestational age at treatment showed significant differences between 2 groups (OR: 0.003, 95% CI: 0.001-0.604).Immediate management after diagnosis could expect favorable prognosis of HP. GA at treatment was the only independent risk factor for miscarriage in patients with HP regardless of treatment methods.

Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies.

BACKGROUND: Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies. METHODS: A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups. RESULTS: Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05). CONCLUSION: With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.