Non-tubal ectopic pregnancy treatment experiences of a tertiary care center.

AIM: To evaluate the incidence, the risk factors, and the treatment outcomes of Non-tubal ectopic pregnancies (NTEP) treated in a tertiary care center. MATERIAL AND METHODS: A total of 110 NTEP cases treated between 2014 and 2019 were included in the retrospective study. The study cohort was divided into 6 groups according to the pregnancy localization: 87 cesarean scar pregnancies (CSPs), 7 ovarian pregnancies, 6 interstitial pregnancies, 4 rudimentary horn pregnancies, 4 abdominal pregnancies, and 2 cervical pregnancies. One woman rejected all treatment modalities. Demographic characteristics, treatment modalities, and outcomes of each group were evaluated. RESULTS: In the study cohort, expectant management was performed in one (0.9%) woman. The methotrexate (MTX) treatment was administered in 29 (26.3%) women. Seventeen (15.4%) women underwent surgery, and 63 (57.2%) women underwent manual vacuum aspiration (MVA). A woman rejected all treatment modalities. Although 70.1% (n = 61) of CSPs were cured with MVA, 24.1% (n = 21) of them were treated with a single-dose MTX regimen in addition to MVA. The higher mean gestational sac size (33,9 ± 12,96 mm vs. 17,34 ± 9,87 mm), the higher mean gestational week (8,43 ± 1,16w vs. 6,66 ± 1,49w), the presence of fetal heartbeat (FHB) (90.5% vs. 26,2%) and the history of pelvic inflammatory disease (PID) (38.1% vs. 6,6%) were found in the CSPs with MVA treatment failure (p < 0.05). CONCLUSION: The management of NTEPs should be individualized according to the clinical and ultrasonographic findings. The size of the ectopic pregnancy mass, the gestational week, the presence of FHB, and the PID history were the predictive factors for the failure of MVA in CSP cases.

Diagnosis and treatment of retroperitoneal ectopic pregnancy: review of the literature.

Retroperitoneal ectopic pregnancies (REP) are extremely rare, and early diagnosis and treatment is very difficult. We completed an English literature search in MEDLINE through PubMed for articles on REP. We identified 14 articles (all case reports) but selected only 12 because of unavailable data in the other 2 articles. We also report the case of an REP which was misdiagnosed as ectopic choriocarcinoma. The 33-year-old woman was admitted via the outpatient department with a history of 54 days of amenorrhea and persistent elevated serum ß-human chorionic gonadotropin (hCG) levels. The presumed diagnosis ectopic choriocarcinoma was made based on imaging findings. Single-drug chemotherapy with methotrexate (MTX; 20-mg intramuscular injection daily for 5 consecutive days) was administered. An upper abdominal mass was noticed by the patient and laparotomy was performed. A retroperitoneal pregnant lesion was found and removed successfully. The diagnosis, treatment and mechanisms of REP are discussed. We believe REP should be considered in patients with elevated serum ß-hCG levels when the uterus and adnexa appear to be normal. Systemic administration of MTX in nonruptured REP before operation may prove to be helpful.

Unusual ectopic pregnancies: a retrospective analysis of 65 cases.

AIM: The aim of this study was to retrospectively investigate unusual ectopic pregnancies (EP) and compare them with fallopian ones. MATERIAL AND METHODS: A total of 1000 cases of ectopic pregnancies were analyzed, including 65 unusual cases. We discussed distribution, incidence, risk factors, examinations, treatments and prognoses. RESULTS: Ovarian pregnancy was associated with placement of intrauterine device and pelvic inflammatory diseases. Extratubal EP have a high rate of misdiagnosis and presented more serious manifestations. Some unusual EP could be diagnosed by ultrasonography. Ovarian pregnancy was usually manifested as positive culdocentesis. Most of the unusual EP underwent surgery, except some early cervical and corneal pregnancies. CONCLUSION: Although extratubal pregnancies are difficult to diagnose, some histories and auxiliary examinations could make diagnosis easier for clinical physicians. Surgery is still the most effective approach for treatment of unusual EP, while conservative treatment of mifepristone combined with methotrexate or curettage could be used for early diagnosis and treatment of cervical pregnancy.

Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment.

Ectopic pregnancy is a very common diagnosis (2% of pregnancies), and implantation location varies. Although 97% of ectopics are implanted within the fallopian tube, associated with commonly recognized risk factors, ectopic implantation can occur in other pelvic and abdominal locations that may not have such predisposing risk factors. After an extensive review of the literature, along with the author's personal experience, implantation frequency, etiologic possibilities, and treatment options for each ectopic pregnancy location are presented. When ectopic pregnancy is diagnosed early, before rupture, regardless of location, conservative, fertility-sparing treatment options can be successful in terminating the pregnancy. Predisposing risk factors and treatment options can vary and can be ectopic-location specific.

Early abdominal ectopic pregnancies: a systematic review of the literature.

OBJECTIVE: To define abdominal ectopic pregnancy outcomes by both location and treatment. METHODS: Literature review of abdominal pregnancies from 1965 to August of 2009. Ectopic pregnancy exclusions were interstitial, tubal, cervical, ovarian, or those beyond 20 weeks at diagnosis/treatment. RESULTS: There were 511 cases identified with 225 meeting the inclusion criteria. There were 7 maternal deaths (3.0%) with 18 (8%) of the early abdominal ectopic pregnancies occurring with an intrauterine device in place. Mean gestational age at the time of treatment was 10 weeks 0 days and mean maternal age was 29.7 years. The average blood loss associated with treatment was 1,450 ml. The top three sites of early abdominal ectopic pregnancies were pouches around the uterus (24.3%), serosal surface of the uterus and tubes (23.9%), and multiple sites (12.8%). Primary surgical management was performed in 208 cases (87.8%). Nonsurgical adjuvant or primary therapy included intramuscular methotrexate, intralesional methotrexate, intracardiac KCl, and artery embolization. CONCLUSION: Abdominal pregnancies should be considered in all patients until an intrauterine location can be confirmed. Understanding treatment options by pregnancy location may be helpful in the management of this potentially life-threatening condition.

A 30-year review of advanced abdominal pregnancy at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria (1976-2006).

PURPOSE: This analysis attempts to highlight the varied presentations, diagnostic difficulties, management and subsequent obstetric performances of women managed for advanced abdominal pregnancy. METHODS: A retrospective analysis of all 20 cases of abdominal pregnancies between 1976 and 2006, at the Mater Misericordiae Hospital, Afikpo, southeastern Nigeria was performed. RESULTS: There were 20 cases of abdominal pregnancy out of 58,000 deliveries, giving an incidence of 0.34 per 1,000 deliveries. The diagnoses were missed in 10 cases and there was one maternal death. There were four live births, two early neonatal deaths and four cases of lithopedion. The placenta was removed in 11 cases. Though the duration of hospital stay was longer in women in whom the placenta was left in situ compared to those in whom the placenta was removed, the observed difference was, however, not statistically significant (p value, 0.538). The majority of the women were lost to follow-up over the years; however, of the five women successfully followed up, only two (40%) had subsequent childbirth. CONCLUSION: The rate of 50% missed diagnosis in this study highlights the need for a high index of suspicion in the diagnosis of abdominal pregnancies as the clinical features are varied. It calls for vigilance on the part of the obstetrician. The maternal and fetal outcomes relate to early diagnosis and skilled management.

Dilatation and curettage versus lesion resection in the treatment of cesarean-scar-pregnancy: A systematic review and meta-analysis.

This meta-analysis was performed to compare the efficacy and safety of dilatation and curettage (D&C) (simply D&C or combined with other treatments) and lesion resection for cesarean scar pregnancy (CSP). A search of English and Chinese databases from 2010 to 2019 was conducted. Thirty one studies were retrieved including sixteen random controlled and fifteen case controlled trials. Compared with abdominal resection surgery(ARS) and vaginal resection surgery(VRS), uterine artery embolization(UAE)+D&C has no obvious difference in curative effect and safety (UAE + D&C versus ARS: Cure rate(CR): P = 0.076, time for menstruation recovery/ß-HCG normalization: P = 0.545/0.949,Blood loss: P = 0.005, adverse event: P = 0.420; versus VRS: CR: P = 0.085, time for menstruation recovery/ß-HCG normalization: P < 0.001/P = 0.031,Blood loss: P = 0.902, adverse event: P = 0.249). UAE + D&C associated with lower blood loss and less postoperative complication than laparoscopic resection surgery(LRS), but LRS take more advantages in terms of the curative effect (CR: P = 0.047, time for menstruation recovery/ß-HCG normalization: P = 0.352/0.103). The efficacy and safety of VRS are better than D&C, methotrexate (MTX) + D&C (D&C versus VRS: CR: P < 0.001, time for ß-HCG normalization: P = 0.363,blood loss: P < 0.001, adverse event: P = 0.046; MTX + D&C versus VRS: CR: P < 0.001, time for menstruation recovery/ß-HCG normalization: P < 0.001/P = 0.005, blood loss: P < 0.001, adverse event: P < 0.001). Lesion resection had advantages in shorter time for menstrual recovery/ß-HCG normalization and less adverse events, lower failure rate over the administration of D&C treatments. In detail, the curative effect of UAE + D&C is similar to ARS and VRS, but inferior to LRS, while the safety of UAE + D&C is better than LRS. The efficacy and safety of simply D&C and MTX + D&C are not as good as VRS.

Clinical efficacy analysis of different therapeutic methods in patients with cesarean scar pregnancy.

OBJECTIVE: The purpose of this study was to analyze the clinical efficacy of five therapeutic strategies in patients with CSP. MATERIALS AND METHODS: A total of 135 CSP patients were included and divided into five groups based on the treatment they received, including transvaginal resection (Group A), laparoscopic resection (Group B), uterine arterial embolization (UAE) combined with hysteroscopic curettage (Group C), UAE combined with uterine curettage (Group D), and hysteroscopic curettage (Group E). To investigate the clinical efficacy of these strategies, intraoperative bleeding, serum ß-hCG levels and recovery time, menstruation recovery time, hormone levels at 1 month after treatment. RESULTS: Patients in group A had the lowest postoperative serum ß-hCG levels, and the shortest recovery times of both serum ß-hCG and menstruation, followed by patients in group B. Group C and D had small amount of blood loss. The hospital stays and costs were low in group E. In addition, the sex hormone levels showed no significant difference among the five groups. CONCLUSION: Our results indicated that resection surgery and UAE have good curative effects, but high hospital costs in CSP treatment. The selection of an optimal treatment regimen for CSP should be carried out based on specific conditions of the patients.

Imaging in the management of abdominal pregnancy: a case report and review of the literature.

BACKGROUND: Abdominal pregnancy is a rare condition that is potentially life-threatening for the mother. CASE: A 29-year-old woman presented with abdominal pain at 17 weeks of pregnancy. An ultrasound scan demonstrated an active abdominal pregnancy. MRI was used for placental localization. After discussion with the woman, it was decided to proceed to termination of the pregnancy. A pelvic angiogram was performed to localize placental vascularization. Both uterine arteries were embolized. Catheterization of the ovarian arteries identified that the right ovarian artery was one of the main vessels supplying the placenta. Selective embolization was performed. Laparotomy was then performed with removal of the fetus, but the placenta was left in place. Use of methotrexate was not required in the postoperative period. The patient was discharged on the seventh postoperative day. Serum BhCG became negative within one month. CONCLUSION: In the management of abdominal pregnancy, the use of imaging and radio-interventional techniques is critical in minimizing surgical and post-surgical interventions.

Super-selective arterial embolization for uncontrolled bleeding in abdominal pregnancy.

BACKGROUND: Abdominal pregnancy with massive bleeding is life-threatening. Thus, multimodal treatment approaches are necessary. CASE: A 36-year-old woman with abdominal pregnancy at 14 weeks of gestation presented with abdominal pain due to intraabdominal bleeding. Laparotomy demonstrated massive bleeding from the placenta implanted in the right lower quadrant involving the posterior uterine wall, right adnexa, and small intestine. Because attempted removal of the placenta aggravated the bleeding, only the fetus was removed. To stop abdominal bleeding, embolization of the placental vasculature was successfully performed with a 2.0-F microcatheter after identification of the bleeding point with computed tomography arteriography. The patient was the treated with methotrexate. CONCLUSION: Super-selective arterial embolization with a microcatheter is a useful treatment of abdominal bleeding due to abdominal pregnancy.

Successful methotrexate treatment of an abdominal pregnancy in the pouch of Douglas.

Abdominal pregnancy is a rare localization of ectopic pregnancy. Early diagnosis and treatment are advised and the choice of treatment is crucial. A successful case of conservative treatment with combined systemic and intra-amniotic methotrexate is presented. This treatment option should be considered in the management of this potentially life-threatening condition.

Splenic Pregnancy: A New Minimally Invasive Approach to Treatment.

The spleen is a rare site of abdominal ectopic pregnancy. In a review of the literature, we found 16 published cases of primary splenic pregnancies. Of the cases identified, all received surgical intervention, with one case successfully treated with laparoscopic methotrexate injection, and the rest underwent splenectomy. We would like to present a case of primary splenic pregnancy in a 35-year-old woman successfully treated with percutaneous image-guided injection of methotrexate and KCl.

Conservative treatment of ectopic pregnancy in a cesarean scar.

BACKGROUND: Pregnancy developing in a cesarean scar is a very rare but possibly life-threatening condition because of the risk of rupture and excessive hemorrhage. CASE: A 34-year-old woman presented with lower abdominal pain at 6 weeks of gestation. A cesarean delivery had been performed 3 years earlier. Transvaginal ultrasound examination revealed a viable pregnancy developing in the anterior wall of the uterus. The patient was treated successfully with systemic methotrexate and curettage. CONCLUSION: Conservative management with methotrexate and curettage can be considered in the treatment of ectopic cesarean scar pregnancy.

Abdominal pregnancy: a cause of failed induction of labour.

BACKGROUND: Induction of labour is a common mode of management of intrauterine fetal deaths, and the process usually involves ripening of the cervix by traditional methods of intracervical Foley's catheter insertion or the use of prostaglandin preparations intravaginally. Such methods are usually very effective independently. The objective of this case report is to call the attention of practising obstetricians to the possibility of an abdominal pregnancy as a cause of failure to ripen the cervix and that careful re-evaluation and use of ultrasound scan can improve diagnostic acumen with favorable outcome of management in such cases METHODS: The case file of the patient was thoroughly reviewed. A literature search on the subject of abdominal pregnancy using local and international journals and relevant textbooks was done to document the current status of the management of such cases. RESULTS: A 29-year-old Gravida 4 para 3+0 (2 alive) presented at an estimated gestational age of 32 weeks with loss of fetal movement, which was suggestive of fetal death and was referred as such from a private hospital. A process of induction of labour was commenced; to ripen the cervix with intracervical Foleys catheter and misoprostol tablet and stimulate uterine contraction, but this was not successful due to failure of the cervix to ripen. This prompted further review of the patient with the aim of excluding the possibility of an abdominal ectopic pregnancy. A repeat ultrasound scan was done and this confirmed a diagnosis of abdominal pregnancy. The patient had laparotomy done to deliver a dead fetus and the placenta was removed with the right tube and ovary as they were deeply embedded in the placental mass. The definitive diagnosis was that of a secondary abdominal pregnancy. She made a satisfactory postoperative recovery and was discharged home. CONCLUSION: A high index of suspicion is needed to make a first time diagnosis of abdominal pregnancy. With timely diagnosis and appropriate management, the prognosis in most cases is favourable.

Abdominal pregnancy in a low-resource setting.

BACKGROUND: Abdominal pregnancies are rare types of ectopic pregnancies with high rates of maternal mortality and morbidity when encountered anywhere in the world. Combining such high-risk pregnancy with the limitations found in a low-resource setting can lead to increased complications, which can be more difficult to manage. CASE: A 21-year-old woman, gravida 2 para 1001, at 36 weeks of gestation presented with a complicated abdominal pregnancy in Cameroon. The patient was followed through multiple complicated surgeries and medical treatments, including chemotherapy, until final resolution and complete recovery. CONCLUSION: This case highlights known complications of advanced abdominal pregnancy, including blood loss and infection. It also emphasizes limitations within the low-resource setting, which can independently add to the patient's morbidity and complicate management, and demonstrates examples of approaches that can be used aid management decisions within low-resource areas.

Minimally invasive management of an advanced abdominal pregnancy.

BACKGROUND: Advanced abdominal pregnancy is a rare, life-threatening condition that presents a number of challenges. CASE: A 29-year-old primigravida with 10 years of secondary infertility and a previous tuboplasty had a 21-week abdominal pregnancy treated with preoperative arterial embolization before laparoscopically assisted fetal delivery. Postoperatively, 4 cycles of methotrexate were administered at 50 mg/m2 intramuscularly every 3 weeks for the retained abdominal placenta. Subsequent spontaneous conception occurred, and a live, full-term infant was delivered by cesarean delivery 17 months later. No adverse sequelae were found during long-term follow-up. CONCLUSION: This report demonstrates successful minimally invasive management of an advanced abdominal pregnancy with a multimodal approach that included preoperative arterial embolization, laparoscopically assisted delivery, and judicious use of postoperative methotrexate.

Ectopic pregnancy causing hemothorax managed by thoracoscopy and actinomycin D.

BACKGROUND: Most patients with extratubal ectopic pregnancies present with vaginal bleeding and lower abdominal pain. We report a case of an extratubal ectopic pregnancy with extra-abdominal manifestations. CASE: An ectopic pregnancy implanted on the diaphragm resulted in spontaneous hemothorax due to trophoblastic invasion into the pleura. Thoracoscopic excision followed by actinomycin D chemotherapy provided successful resolution of the ectopic pregnancy. CONCLUSION: Abdominal pregnancies may have bizarre clinical presentations.

Expectant management of abdominal pregnancy. A report of two cases.

In two recent consecutive cases of abdominal pregnancy the diagnosis was made at 18 weeks' gestation, and the patients refused immediate surgery and elected to maintain the pregnancy until fetal viability developed. Both patients were managed expectantly with continuous antepartum hospitalization. Fetal assessment was by serial ultrasound assessment of growth and amniotic fluid volume and by nonstress testing. Planned operative delivery was accomplished at 28 1/2 weeks and 33 weeks' gestation. In the second case the diagnosis was confirmed by magnetic resonance imaging. That fetus was also assessed with umbilical artery Doppler flow studies. Despite significant morbidity, both the mothers and infants are alive and well.

Embolization for advanced abdominal pregnancy with a retained placenta. A case report.

BACKGROUND: Abdominal pregnancy is not encountered commonly, and management of the placenta is controversial. CASE: A 33-year-old woman presented with an abdominal pregnancy at 33 weeks' gestation with fetal death. The placental vasculature was embolized preoperatively. Following operative delivery. of the fetus, the placenta was left in situ in efforts to preserve fertility given its implantation on the reproductive organs. The patient suffered prolonged postoperative ileus but otherwise did well. Placental function ceased after two months. CONCLUSION: Placental vasculature embolization is a management option for a retained placenta associated with abdominal pregnancy.