Características del abdomen agudo quirúrgico gineco-obstétrico en un hospital público de Paraguay (2015-2020)

Introducción: El abdomen agudo gineco-obstétrico es uno de los problemas más desafiantes en la práctica médica y en algunas situaciones pone en peligro la vida de las pacientes. Objetivo: Determinar las características del abdomen agudo quirúrgico gineco-obstétrico en el Hospital Regional de Ciudad del Este durante el periodo 2015 al 2020. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo, con muestreo no probabilístico; que incluyó pacientes con cuadro de abdomen agudo quirúrgico que ingresaron al servicio de gineco-obstetricia durante el periodo comprendido desde 1 de octubre del año 2015 hasta 30 de setiembre del año 2020. Datos sociodemográficos, causas gineco-obstétricas, diagnósticos etiológicos, complicaciones, condiciones al egreso se tuvieron en cuenta. Los datos fueron analizados en el software Stata 12.0®. Resultados: Se estudiaron a 375 pacientes, 55% presentan edades comprendidas entre 20 a 35 años y procedente de zona urbana en un 84%. Se evidenciaron que el 51% fueron de causa obstétrica, el 40% ginecológico y el 9% de causas no gineco-obstétricas. El embarazo ectópico complicado fue del 46% de los casos. El 38% de las complicaciones presentaron sepsis y el 35% shock hipovolémico. Las complicaciones quirúrgicas en el puerperio se registraron que la endometritis/peritonitis fue del 47% y dehiscencia de histerorrafia/absceso de pared con 33%. El 7% de las pacientes fueron derivadas a unidad de cuidados intensivos. Conclusión: El abdomen agudo quirúrgico gineco-obstétrico es más frecuente en edades medias, predomina las causas obstétricas. De entre las etiologías, el embarazo ectópico es la más frecuente. Entre las causas obstétricas de las gestantes con fetos viables sigue siendo la apendicitis aguda. El cuadro séptico y el shock hipovolémico predominan entre las complicaciones. En el puerperio la endometritis y peritonitis. Y, por último, se registraron un porcentaje considerado de requerimiento de cuidados intensivos.

Introduction: The acute gynecological-obstetric abdomen is one of the most challenging problems in medical practice and in some situations it endangers the lives of patients. Objective: Determine the characteristics of the gynecological-obstetric surgical acute abdomen at the Ciudad del Este Regional Hospital during the period 2015 to 2020. Materials and methods: Observational, descriptive, retrospective study, with non-probabilistic sampling. All patients with acute surgical abdomen who were admitted to the gynecology-obstetrics service were studied during the period from October 1, 2015 to September 30, 2020. The data were analyzed in the Stata 12.0® software. Results: 375 patients were studied, of which 51% had obstetric causes, 40% had gynecological causes, and 9% had non-gynecological-obstetric causes. It was evident that 55% were between 20 and 35 years old, with 84% coming from urban areas. Complicated ectopic pregnancy was 46% of cases. 38% of the complications presented sepsis and 35% hypovolemic shock. Surgical complications in the puerperium were recorded: Endometritis/peritonitis was 47% and hysterography/wall abscess dehiscence was 33%. 7% of the patients were referred to the intensive care unit. Conclusion: Obstetric-gynecological surgical acute abdomen is more common in middle ages, obstetric causes predominate. Among the etiologies, ectopic pregnancy is the most common. Acute appendicitis continues to be among the obstetric causes of pregnant women with viable fetuses. Septic symptoms and hypovolemic shock predominate among the complications. In the puerperium, endometritis and peritonitis. And finally, a percentage considered to require intensive care was recorded.

Hysteroscopic subchorionic injection of methotrexate followed by laparoscopic excision of the gestational sac for the management of cesarean scar ectopic pregnancy: an innovative dual approach of a challenging pathology.

OBJECTIVE: To describe an effective two-step surgical approach for the management of cesarean scar ectopic pregnancies (CSEPs). CSEPs occur at an estimated frequency of 1 in 1,800 pregnancies, constituting approximately 6% of ectopic pregnancies in women with a history of prior cesarean delivery [1, 2]. Despite numerous recommended therapeutic approaches, the most effective treatment strategy remains uncertain [3]. DESIGN: We present an innovative double-step technique for the management of a patient with a CSEP involving hysteroscopic subchorionic injection of methotrexate (MTX), followed by laparoscopic resection of the residual gestational sac and simultaneous repair of the uterine defect. SETTING: Academic tertiary hospital. PATIENT: A 34-year-old G2P1001 with a history of prior cesarean section presented at 10 weeks of gestation. Ultrasound revealed a gestational sac within the niche of the previous cesarean scar, confirming the diagnosis of a CSEP. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, among others), and other applicable sites. INTERVENTION: The initial treatment involved hysteroscopic administration of MTX within the placental intervillous spaces, ensuring precise medication delivery. The administered dose of MTX was 1 mg/kg. Following the normalization of beta-human chorionic gonadotrophin (ß-hCG) levels, laparoscopic resection of the remaining gestational sac and reconstruction of the uterine wall defect were performed. MAIN OUTCOME MEASURES: We have implemented a management strategy focusing on ectopic pregnancy removal and addressing defect revision. The hysteroscopic approach allows for a clear assessment of the ectopic pregnancy and facilitates precise MTX administration, enhancing its effectiveness by increasing drug concentration within the placental intervillous space. Delaying surgical repair until after the ß-hCG levels have decreased reduces the risk of excessive bleeding during the procedure, as lower ß-hCG levels are associated with reduced vascularity at the ectopic site. Subsequent laparoscopic resection allows for complete removal of the remaining products of conception and repair of the defect, preserving the uterus and restoring normal anatomy. Compared to other surgical approaches, our two-step approach enables a more precise evaluation of placental implantation, making it a highly effective surgical method. RESULTS: We successfully managed a CSEP using a double-step technique. This involved hysteroscopic injection of subchorionic MTX, followed by laparoscopic resection of the residual gestational sac. Concurrently, we repaired the uterine defect. Both procedures were performed in an outpatient setting without complications detected during or after treatment. At the follow-up visit, the patient reported good health, and subsequent ultrasound confirmed an empty isthmocele. CONCLUSION: This sequential hysteroscopic and laparoscopic approach represents a definitive and effective minimally invasive surgical option for the treatment of CSEP.

Embarazo pretérmino intrabdominal exitoso: Reporte de caso / Successful intrabdominal preterm pregnancy: A case report

RESUMEN Introducción: El embarazo ectópico es toda gestación, en la que el sitio de implantación del óvulo fecundado se localiza fuera de la cavidad endometria y representa el 1.4 % de estos. Caso clínico: Paciente de 28 años con dos cesáreas previas, sometida a salpingoclasia durante la última intervención. La paciente ingresó al hospital con presión arterial de 180/130 mm Hg, no respondió a tratamiento médico y presentó falla en la progresión de trabajo de parto, por lo que se decidió interrupción por operación cesárea. Durante la cirugía, se observó un pequeño útero con embarazo extrauterino adherido a la serosa del ciego, el colon ascendente y el apéndice. Se obtuvo un producto femenino pretérmino vivo; la madre cursó con evolución favorable y sin complicaciones posoperatorias. Conclusión: La presentación del embarazo abdominal ectópico es rara, por lo que un control prenatal adecuado por personal capacitado puede orientar a la sospecha diagnóstica. La madre y la recién nacida no presentaron ninguna complicación, a pesar de ser un embarazo abdominal avanzado y la inserción multifocal de la placenta. Se resalta la importancia del manejo oportuno y multidisciplinario cuando se enfrentan embarazos con curso anormal para la mejor evolución de la madre y del producto.

ABSTRACT Introduction: Ectopic pregnancy is any gestation in which the implantation site of the fertilized egg is located outside the endometrial cavity. Abdominal ectopic pregnancy represents 1.4% of these. Case report: 28-year-old patient with two previous cesarean sections; bilateral tubal obstruction during the last operation. The patient was admitted to the hospital with blood pressure of 180/130 mm Hg that did not respond to medical treatment and not progression to labor so it was decided to interrupt the pregnancy by cesarean section. During surgery, a small uterus with extrauterine pregnancy was observed adhered to the serosa of the cecum, ascending colon, and appendix. A live preterm female product was obtained; the mother had a favorable evolution and no postoperative complications. Conclusion: Ectopic pregnancies are rera. An adequate prenatal control by well trained personnel is essential for an accurate diagnosis. The mother and the newborn did not present any complication. It is very important to have and accurate an opportune diagnosis so trained personnel can offer an adequate management.

Spontaneous bilateral tubal ectopic pregnancy: a gynecological challenge.

Bilateral ectopic pregnancy is very rare. Although the frequency of ectopic bilateral pregnancy has increased with the advent of medically assisted procreation, spontaneous bilateral tubal pregnancies remain rare. Early detection of this type of ectopic pregnancy is important to prevent maternal mortality and morbidity. Conservative surgery must also be considered, as preservation of both tubes is presumed to offer better fertility prospects. We report the case of a 35-year-old patient at five weeks of amenorrhea with bilateral ectopic pregnancy diagnosed based on ultrasound scans and confirmed during laparotomy. A 35-year-old woman with a history of three vaginal deliveries, non-smoker, on contraceptives (microprogestins), presented with pelvic pain and amenorrhea of five weeks. A beta HCG test came back positive. Pelvic ultrasound revealed a moderate hemoperitoneum and an empty uterus with hematometra. It also showed heterogeneous left and right adnexal masses measuring 3 cm and 4 cm, respectively. An emergency laparotomy was performed. Per-operatively, two bilateral tubal pregnancies of 3 cm and 4 cm were founded. The patient received conservative treatment with bilateral salpingotomy. Postoperative management was uneventful. The diagnosis of spontaneous bilateral tubal ectopic pregnancy is rare and often established at the time of surgery, hence the importance of a rigorous and vigilant examination of the two tubes during ultrasound examination and surgery, so as not to miss it and to better prevent maternal mortality. Conservative surgery must be carefully chosen.

The impact of the coronavirus disease 2019 pandemic on the clinical presentation of tubal ectopic pregnancies: a retrospective cohort study

SUMMARY OBJECTIVE: We aimed to assess the impact of the coronavirus disease 2019 pandemic on the clinical presentation of tubal ectopic pregnancies. METHODS: This retrospective cohort study was conducted at a tertiary center and included 76 cases of tubal ectopic pregnancies. The study period was divided into two groups: the pre-coronavirus disease group (January 2018 to February 2020, Group 1; n=47, 61.8%) and the coronavirus disease group (March 2020 to February 2022, Group 2; n=29, 38.2%). Subgroup analysis was also performed for tubal ruptured ectopic pregnancies as Group 1 (n=15, 62.5%) and Group 2 (n=9, 37.5%). RESULTS: No statistically significant differences were observed between the pre-coronavirus disease and coronavirus disease groups in terms of demographic characteristics. Although the serum beta-human chorionic gonadotropin level was found to be higher in Group 2, the difference was not statistically significant (p=0.7). The groups appeared to be similar in treatment management, duration of hospitalization, and blood transfusion needs (p=0.3, p=0.6, and p=0.5, respectively). Additionally, no significant difference was observed between the groups in the evaluation of ruptured ectopic pregnancies (p=0.5). In the subgroup analysis of tubal ruptured ectopic pregnancies, no significant difference was observed. CONCLUSION: To the best of our knowledge, there are few studies evaluating the effect of the pandemic on tubal ectopic pregnancies in the literature. Although we did not report statistically significant differences between groups in our study, given the potential prolonged duration of the pandemic, healthcare professionals should actively prompt their patients to seek necessary medical assistance.

Tubal ectopic pregnancy: comparative management between pre and Covid-19 pandemic periods

Abstract Objective: To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic. Methods: We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications. Results: We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003). Conclusion: We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.

Embarazo Ectópico Cornual: Reporte De Una Localización Inusual / Interstitial ectopic pregnancy: report of an unusual location

Resumen Se define a un embarazo ectópico cuando el blas tocisto en desarrollo se implanta fuera de la cavidad uterina. La localización más frecuente es en la trom pa, pero también puede ocurrir en el ovario, cérvix, cicatriz de cesárea, cuerno uterino (también mencio nado como intersticial en la literatura) o abdominal. Se estima que la incidencia de embarazo ectópico es aproximadamente el 2% de todos los embarazos, sien do la localización cornual solo el 2-4% de esos casos. El objetivo de este reporte es describir el caso de una paciente con sospecha de embarazo ectópico de loca lización incierta a quien se le realizó una laparoscopia exploradora por inicio de síntomas, evidenciando un embarazo ectópico cornual en el lecho de una salpin gectomía, producto de un embarazo ectópico tubario previo. Se realizó la cornuotomía con resección del mismo por laparoscopia y su evolución fue favorable con negativización de la subunidad beta. Este tipo de localización es rara y se asocia con grandes tasas de morbimortalidad materna. Representa un desafío diagnóstico y terapéutico para el ginecólogo que lo enfrenta.

Abstract Ectopic pregnancy occurs when a developing blastocyst implants at any site other than the uterine cavity. Ectopic pregnancy is most commonly found in the fallopian tube but may also occur in the cornua of the uterus (also found as interstitial in the literature), cervix, ovary, or abdominal cavity or in a cesarean scar. An estimated 2% of pregnan cies are ectopic, of which an interstitial pregnancy repre sents an extremely rare variant of ectopic pregnancy (EP), accounting for 2% to 4 % of all cases. The aim of this report is to describe the case of a patient with suspected ectopic pregnancy of uncertain location in which an exploratory laparoscopy was performed due to the onset of symptoms, discovering a cornual ectopic pregnancy in site of a past salpingectomy because of a tubal ectopic pregnancy. A cornuotomy by laparoscopy was performed to resect the cornual ectopic pregnancy. The patient had an unevent ful postoperative course, with negativization of human chorionic gonadotropin levels. This type of location is rare and is associated with high rates of maternal morbidity and mortality. It represents a diagnostic and therapeutic challenge for the gynecologist who faces it.

[Interstitial ectopic pregnancy: report of an unusual location]. / Embarazo ectópico cornual: reporte de una localización inusual.

Ectopic pregnancy occurs when a developing blastocyst implants at any site other than the uterine cavity. Ectopic pregnancy is most commonly found in the fallopian tube but may also occur in the cornua of the uterus (also found as interstitial in the literature), cervix, ovary, or abdominal cavity or in a cesarean scar. An estimated 2% of pregnancies are ectopic, of which an interstitial pregnancy represents an extremely rare variant of ectopic pregnancy (EP), accounting for 2% to 4 % of all cases. The aim of this report is to describe the case of a patient with suspected ectopic pregnancy of uncertain location in which an exploratory laparoscopy was performed due to the onset of symptoms, discovering a cornual ectopic pregnancy in site of a past salpingectomy because of a tubal ectopic pregnancy. A cornuotomy by laparoscopy was performed to resect the cornual ectopic pregnancy. The patient had an uneventful postoperative course, with negativization of human chorionic gonadotropin levels. This type of location is rare and is associated with high rates of maternal morbidity and mortality. It represents a diagnostic and therapeutic challenge for the gynecologist who faces it.

Se define a un embarazo ectópico cuando el blastocisto en desarrollo se implanta fuera de la cavidad uterina. La localización más frecuente es en la trompa, pero también puede ocurrir en el ovario, cérvix, cicatriz de cesárea, cuerno uterino (también mencionado como intersticial en la literatura) o abdominal. Se estima que la incidencia de embarazo ectópico es aproximadamente el 2% de todos los embarazos, siendo la localización cornual solo el 2-4% de esos casos. El objetivo de este reporte es describir el caso de una paciente con sospecha de embarazo ectópico de localización incierta a quien se le realizó una laparoscopia exploradora por inicio de síntomas, evidenciando un embarazo ectópico cornual en el lecho de una salpingectomía, producto de un embarazo ectópico tubario previo. Se realizó la cornuotomía con resección del mismo por laparoscopia y su evolución fue favorable con negativización de la subunidad beta. Este tipo de localización es rara y se asocia con grandes tasas de morbimortalidad materna. Representa un desafío diagnóstico y terapéutico para el ginecólogo que lo enfrenta.

Uso de mifepristona en embarazo ectópico intersticial: un reporte de caso / Use of mifepristone in an interstitial ectopic pregnancy: a case report

Introducción: El embarazo ectópico intersticial es una forma de presentación poco frecuente, con una incidencia del 2-4% de los embarazos ectópicos; sin embargo, a pesar de su baja incidencia la mortalidad es cinco veces mayor, impactando en las cifras de mortalidad materna y representando en torno al 10-15% de los casos. Objetivo: Presentar un caso de embarazo ectópico intersticial, cuya ocurrencia es poco frecuente, así como el abordaje satisfactorio del manejo médico con mifepristona y metotrexato. Caso clínico: Mujer de 28 años con antecedente de resección tubárica por quiste paraovárico derecho, quien acudió a urgencias por hallazgo en ecografía obstétrica de sospecha de embarazo intersticial izquierdo y se le administró manejo farmacológico con dosis de metotrexato y mifepristona, con éxito. Conclusiones: El manejo médico con metotrexato y mifepristona para el embarazo ectópico intersticial parece ser una elección eficaz en los casos con estabilidad hemodinámica y deseo de conservación de la fertilidad.

Background: Interstitial ectopic pregnancy represents a rare form of presentation, with an incidence of 2-4% of all ectopic pregnancies. However, despite its low incidence, it is associated with a five-fold increase in mortality, significantly impacting maternal mortality rates, accounting for approximately 10-15% of cases. Objective: To present a case of interstitial ectopic pregnancy, which is a rare occurrence, as well as the successful medical management approach with mifepristone and methotrexate. Case report: A 28-year-old women with a history of right paraovarian cyst tubal resection presented to the emergency department due to suspected left interstitial pregnancy identified on obstetric ultrasound. The patient was successfully managed with pharmacological treatment using doses of methotrexate and mifepristone. Conclusions: Medical management with methotrexate and mifepristone for interstitial ectopic pregnancy appears to be an effective choice in cases with hemodynamic stability and a desire for fertility preservation.

Caracterización clínico-epidemiológica de pacientes operadas de embarazo ectópico en la provincia de Camagüey / Clinical-Epidemiological Characterization of Patients Operated on for Ectopic Pregnancy in Camagüey Province

Introducción: Los datos clínicos y antecedentes epidemiológicos resultan de vital importancia en el diagnóstico oportuno del embarazo ectópico. Objetivo: Determinar las características clínico-epidemiológicas de pacientes operadas de embarazo ectópico. Métodos: Se diseñó y se realizó un estudio descriptivo, de corte transversal, tipo serie de casos en un universo de 130 pacientes operadas de embarazo ectópico en el Hospital Ginecobstétrico de Camagüey durante el período comprendido de enero a diciembre de 2020. Las variables estudiadas incluyeron: grupos de edades, color de la piel, municipio de procedencia, factores de riesgo, signos y síntomas, así como localización y estado hemodinámico. Resultados: Primaron las pacientes en el grupo de edad de 30-34 años (32,3 porciento), color de piel blanca (76,9 porciento), procedentes del municipio Camagüey (68,5 porciento). La tasa de incidencia provincial por cada 100 embarazos se ubicó en 2,2 porciento, superada por los municipios Camagüey (3,5 porciento) y Jimaguayú (3,0 porciento). El principal factor de riesgo identificado fue el tabaquismo (66,2 porciento), en tanto el dolor abdominal estuvo presente en el 100 porciento de los casos. Se reportó con mayor frecuencia la localización tubárica (91,0 porciento), y el 59,1 porciento se clasificó como no accidentado. Conclusiones: Se determinaron ciertas características en la serie estudiada, de acuerdo con la preponderancia de la variable de los signos y síntomas según los grupos de edades, como elemento a tener en cuenta. La presencia mayoritaria de factores de riesgo modificables supone que sobre estos se debe intervenir desde la atención primaria de salud(AU)

Introduction: Clinical data and epidemiological background are of vital importance for the timely diagnosis of ectopic pregnancy. Objective: To determine the clinical-epidemiological characteristics of patients operated on for ectopic pregnancy. Methods: A descriptive, cross-sectional study of case series type was designed and carried out in a universe of 130 patients operated on for ectopic pregnancy at the gynecobstetric hospital of Camagüey during the period from January to December 2020. The studied variables included age groups, skin color, municipality of origin, risk factors, signs and symptoms, as well as localization and hemodynamic status. Results: There was a predominance of patients in the age group of 30-34 years (32.3 percent), white skin color (76.9 porciento), and from the municipality of Camagüey (68.5 ). The provincial incidence rate per 100 pregnancies was 2.2 porciento, surpassed by the municipalities of Camagüey (3.5 percent and Jimaguayú (3.0 percent). The main identified risk factor was smoking (66.2 percent), while abdominal pain was present in 100 percent of the cases. Tubal location was the most frequently reported (91.0 percent), and 59.1 percent were classified as unruptured. Conclusions: Certain characteristics were determined in the studied series, according to the preponderance of the variable of signs and symptoms by age groups, as an element to be taken into account. The majority presence of modifiable risk factors implies that these should be addressed by primary health care(AU)

A rare case of ectopic partial molar pregnancy following IVF.

A 29-year-old female who received assisted reproductive therapy (IVF) in our infertility clinic, at gestational age of 7w + 2d following embryo transfer, presented with a favorable rise of ß-hCG level with no detectable gestational sac in the uterine cavity in the vaginal ultrasonogram. First dose of MTX (78) with simultaneous ß-hCG titration of 110,000 pg/mL was administered. The patient underwent a second TVS in which a mass in favor of molar ectopic pregnancy was reported. With the suspicion of a molar EP the patient underwent explorative laparotomy. A 3x4 cm mass which was found adjacent to the right ovary was resected. Final pathology report was compatible with partial molar pregnancy. In the follow up period after surgical resection the patient recovered completely without any recurrence.

Tratamiento del embarazo ectópico implantado en cicatriz de cesárea: estudio de cohorte 2018-2022, Lima, Perú / Treatment of ectopic pregnancy implanted on cesarean scar: cohort study 2018-2022, Lima, Peru

Objetivos: Describir las características clínicas y el tratamiento del embarazo ectópico implantado en la cicatriz de cesárea, así como las complicaciones y el pronóstico obstétrico. Materiales y métodos: Estudio de cohorte retrospectivo de gestantes con diagnóstico de embarazo ectópico implantado en la cicatriz de cesárea según los criterios de la Sociedad de Medicina Materno-Fetal, atendidas entre enero de 2018 y marzo de 2022 en dos instituciones de alta complejidad, pertenecientes a la seguridad social, ubicadas en Lima, Perú. Se hizo un muestreo consecutivo. Se midieron variables sociodemográficas y clínicas de ingreso, diagnóstico, tipo de tratamiento, complicaciones y pronóstico obstétrico. Se hace un análisis descriptivo. Resultados: Se incluyeron 17 pacientes, de 29.919 partos. De estas, el 41,2 % recibió tratamiento médico y el resto recibió tratamiento quirúrgico. Se realizó un manejo local exitoso con metotrexato en el saco gestacional en dos pacientes con ectópico tipo 2. Cuatro de las pacientes requirieron histerectomía total. Seis pacientes experimentaron una gestación después del tratamiento, y 4 de ellas culminaron el embarazo con una madre y un neonato saludables. Conclusiones: El embarazo ectópico implantado en la cicatriz de una cesárea es una entidad poco frecuente, para la cual se cuenta con alternativas de manejo médico y quirúrgico con aparentes buenos resultados. Se requieren más estudios con mayor calidad metodológica de asignación aleatoria que ayuden a caracterizar la seguridad y la efectividad de las diferentes alternativas terapéuticas para las mujeres con sospecha de esta patología.

Objectives: To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis. Material and methods: Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed. Results: Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs. Conclusions: Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.

Treatment of ectopic pregnancy implanted on cesarea scar: cohort study 2018-2022, Lima, Peru / Tratamiento del embarazo ectópico implantado en cicatriz de cesárea: estudio de cohorte 2018-2022, Lima, Perú

Objectives: To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis. Material and methods: Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed. Results: Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs. Conclusions: Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.

Objetivos: describir las características clínicas y el tratamiento del embarazo ectópico implantado en la cicatriz de cesárea, así como las complicaciones y el pronóstico obstétrico. Materiales y métodos: estudio de cohorte retrospectivo de gestantes con diagnóstico de embarazo ectópico implantado en la cicatriz de cesárea según los criterios de la Sociedad de Medicina Materno-Fetal, atendidas entre enero de 2018 y marzo de 2022 en dos instituciones de alta complejidad, pertenecientes a la seguridad social, ubicadas en Lima, Perú. Se hizo un muestreo consecutivo. Se midieron variables sociodemográficas y clínicas de ingreso, diagnóstico, tipo de tratamiento, complicaciones y pronóstico obstétrico. Se hace un análisis descriptivo. Resultados: se incluyeron 17 pacientes, de 29.919 partos. De estas, el 41,2 % recibió tratamiento médico y el resto recibió tratamiento quirúrgico. Se realizó un manejo local exitoso con metotrexato en el saco gestacional en dos pacientes con ectópico tipo 2. Cuatro de las pacientes requirieron histerectomía total. Seis pacientes experimentaron una gestación después del tratamiento, y 4 de ellas culminaron el embarazo con una madre y un neonato saludables. Conclusiones: el embarazo ectópico implantado en la cicatriz de una cesárea es una entidad poco frecuente, para la cual se cuenta con alternativas de manejo médico y quirúrgico con aparentes buenos resultados. Se requieren más estudios con mayor calidad metodológica de asignación aleatoria que ayuden a caracterizar la seguridad y la efectividad de las diferentes alternativas terapéuticas para las mujeres con sospecha de esta patología.

Análise das gestações ectópicas íntegras tratadas com o protocolo de dose única de metotrexato / Analysis of unruptured ectopic pregnancies treated with single-dose methotrexate protocol

Objetivo: Avaliar o índice de sucesso do tratamento da gravidez ectópica com o protocolo de dose única do metotrexato e verificar sua correlação com variáveis clínicas e dados dos exames complementares. Métodos: É um estudo epidemiológico observacional, analítico, retrospectivo, de delineamento transversal. Foi realizado de janeiro de 2014 a agosto de 2020 em um hospital público, de ensino, em nível terciário, do Sul do Brasil. Em 73 casos com diagnóstico de gestação ectópica íntegra, foi utilizado o protocolo de dose única de metotrexato intramuscular, com a dose de 50 mg/m2 de superfície corporal. As variáveis do estudo foram relacionadas ao sucesso do tratamento e abordaram as características clínicas na admissão, dos exames complementares e do tratamento realizado. As variáveis foram comparadas por análise de regressão de Poisson. O nível de significância estabelecido foi de p < 0,05. Resultados: O índice de sucesso foi de 83,6%, e em nove casos foi necessária uma segunda dose da medicação. Nível de ß-hCG inicial superior a 5.000 mUI/mL foi relacionado a menor chance de sucesso (odds ratio ajustado de 0,20 [0,05-0,95]). Tamanho da imagem anexial, presença de líquido livre na cavidade abdominal e demais variáveis estudadas não afetaram a chance de sucesso do tratamento. Conclusão: O protocolo de dose única de metotrexato mostrou-se uma opção válida para o tratamento da gestação ectópica íntegra, notadamente quando o nível de ß-hCG inicial é inferior 5.000 mUI/mL.

Objective: The purpose of the present study is to evaluate the success rate of treatment of ectopic pregnancy with the single-dose methotrexate protocol and to verify its correlation with clinical variables and complementary exam data. Methods: This is a retrospective epidemiological observational analytical cross-sectional study. It was carried out from January 2014 to August 2020 in a tertiary level teaching hospital in southern Brazil. In 73 cases with a diagnosis of intact ectopic pregnancy, the intramuscular methotrexate single-dose protocol was applied with a dose of 50 mg/m2 of body surface. The study variables were related to the success of the treatment and addressed the clinical characteristics on admission, the complementary exams and the treatment performed. The variables were compared by Poisson regression analysis. The level of significance was set at p < 0.05. Results: The success rate was 83.6%, and in nine cases a second dose of the medication was necessary. An initial ß-hCG level greater than 5,000 mIU/mL was related to a lower chance of success (adjusted odds ratio of 0.20 [0.05- 0.95]). The size of the adnexal image, the presence of free fluid in the abdominal cavity and other variables studied did not affect the chance of a successful treatment. Conclusion: The methotrexate single-dose protocol proved to be a valid option for the treatment of intact ectopic pregnancy, notably when the initial ß-hCG level is below 5,000 mIU/mL.

Ectopic pregnancy with a contralateral corpus luteum: Case report.

The following report describes the case of an ectopic pregnancy with contralateral corpus luteum after spontaneous conception. The patient was a 33- year-old female (gravida 3, segmentary C sections 3), with positive pregnancy test, and an Intrauterine Device (IUD). The patient was asymptomatic. At vaginal ultrasound, we observed an anteverted uterus of normal shape and size, a 20 x 12 mm intramural myoma and an irregular endometrial thickness of 16.5 mm, with no intrauterine sac. An ectopic pregnancy in the left Fallopian tube and a contralateral corpus luteum were detected, possibly as consequence of ovum pick up through the opposite tube (oocyte transmigration). Further laparoscopic and histopathologic studies confirmed our findings, and the ectopic pregnancy was successfully removed. In conclusion, oocyte transmigration is a common event and should be account when we wish to provide medical advice to patients with a single Fallopian tube trying to conceive. There are real chances for a patient to become pregnant even when only a single tube is present.

A case report of a successful multidisciplinary management of an abdominal pregnancy / Manejo multidisciplinario exitoso del embarazo abdominal. Reporte de un caso peruano

Abdominal pregnancy is defined as one that occurs outside of the uterus and fallopian tubes in the abdominal cavity. We present the case of a 30-year-old Peruvian female patient from Lima with a surgical history of exploratory laparotomy due to tubal ectopic pregnancy and appendectomy without further relevant personal or family histories. She attended the emergency room of a social security hospital in Peru with a referral from a district hospital and a diagnosis of abdominal pregnancy at 14 weeks of gestational age without previous prenatal controls. Symptomatology at hospital admission was colic-type abdominal pain in the hypogastrium without vaginal bleeding, fluid loss or fever. During hospitalization, she underwent an exploratory laparotomy with embolization of the uterine artery, left salpingectomy, and removal of the abdominal ectopic pregnancy. The evolution was favorable after the surgery, and she was discharged. Without further complications, she continues her controls at the obstetrics and gynecology outpatient service without complications.

El embarazo abdominal es aquel embarazo que ocurre fuera del útero y las trompas de Falopio en la cavidad abdominal. Presentamos el caso de una paciente peruana de 30 años proveniente de la ciudad de Lima, con antecedentes quirúrgicos de laparotomía exploradora por embarazo ectópico tubárico y apendicectomía, sin otras patologías ni antecedentes familiares de importancia. La paciente acude al servicio de urgencias de un hospital del seguro social en Perú derivada de un hospital distrital con diagnóstico de embarazo abdominal a las 14 semanas de edad gestacional, sin controles prenatales previos. La sintomatología al ingreso hospitalario fue dolor abdominal de tipo cólico a nivel del hipogastrio, sin sangrado vaginal, pérdida de líquidos o fiebre. Durante su hospitalización se le realizó una laparotomía exploratoria con embolización de la arteria uterina, salpingectomía izquierda y extracción del embarazo abdominal. La evolución fue favorable tras la intervención quirúrgica, siendo dada de alta. Actualmente continúa sus controles en el servicio de consulta externa del servicio de ginecología y obstetricia sin complicaciones.

A case report of a successful multidisciplinary management of an abdominal pregnancy.

Abdominal pregnancy is defined as one that occurs outside of the uterus and fallopian tubes in the abdominal cavity. We present the case of a 30-year-old Peruvian female patient from Lima with a surgical history of exploratory laparotomy due to tubal ectopic pregnancy and appendectomy without further relevant personal or family histories. She attended the emergency room of a social security hospital in Peru with a referral from a district hospital and a diagnosis of abdominal pregnancy at 14 weeks of gestational age without previous prenatal controls. Symptomatology at hospital admission was colic-type abdominal pain in the hypogastrium without vaginal bleeding, fluid loss or fever. During hospitalization, she underwent an exploratory laparotomy with embolization of the uterine artery, left salpingectomy, and removal of the abdominal ectopic pregnancy. The evolution was favorable after the surgery, and she was discharged. Without further complications, she continues her controls at the obstetrics and gynecology outpatient service without complications.

El embarazo abdominal es aquel embarazo que ocurre fuera del útero y las trompas de Falopio en la cavidad abdominal. Presentamos el caso de una paciente peruana de 30 años proveniente de la ciudad de Lima, con antecedentes quirúrgicos de laparotomía exploradora por embarazo ectópico tubárico y apendicectomía, sin otras patologías ni antecedentes familiares de importancia. La paciente acude al servicio de urgencias de un hospital del seguro social en Perú derivada de un hospital distrital con diagnóstico de embarazo abdominal a las 14 semanas de edad gestacional, sin controles prenatales previos. La sintomatología al ingreso hospitalario fue dolor abdominal de tipo cólico a nivel del hipogastrio, sin sangrado vaginal, pérdida de líquidos o fiebre. Durante su hospitalización se le realizó una laparotomía exploratoria con embolización de la arteria uterina, salpingectomía izquierda y extracción del embarazo abdominal. La evolución fue favorable tras la intervención quirúrgica, siendo dada de alta. Actualmente continúa sus controles en el servicio de consulta externa del servicio de ginecología y obstetricia sin complicaciones.

Expectant management of viable cesarean scar pregnancies: a systematic review.

OBJECTIVE: Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended given the risk of life-threatening complications. In some cases, patients refuse to terminate viable CSPs, even after counseling. Recent studies report that, even with a high burden of possible complications and maternal morbidity, many CSPs progress to live, close to term births. The aim of this study is to further demonstrate the natural history of viable cesarean scar pregnancies. METHODS: We conducted a systematic review of original studies reporting cases of expectant management of CSPs with positive fetal heartbeats. RESULTS: After selection, 28 studies were included in the review, with a total of 398 cases of CSP, 136 managed expectantly and 117 with positive fetal heartbeat managed expectantly. This study confirmed that the majority of patients experience live births, as 78% of patients selected for expectant management experienced live births at or close to term, with 79% developing morbidly adherent placenta, 55% requiring hysterectomy, and 40% having severe bleeding. DISCUSSION: The optimal management protocol for CSP is still to be defined and more studies are needed to further elucidate this rare but rising disease. Our study provides information on the natural history of untreated CSPs and suggests that termination may not be the only option offered to the patient.

Diagnosing ectopic pregnancy using Bayes theorem: a retrospective cohort study.

OBJECTIVE: To verify the accuracy of an online algorithm using Bayes' theorem for diagnosing ectopic pregnancy (EP) using human chorionic gonadotropin (hCG), ultrasound, and clinical data in a real cohort. DESIGN: A retrospective cohort study. SETTING: Gynecologic emergency unit in a tertiary teaching hospital. PATIENT(S): First-trimester pregnant women who attended the gynecologic emergency unit for any reason. Those who had <13 weeks of pregnancy confirmed by a recent positive pregnancy test; a digital image or electronic report of transvaginal ultrasound (TVUS) obtained from hospital database; and a follow-up with a pathology report or a clinical resolution of a confirmed pregnancy were included in the study. Clinical signs and symptoms, the presence of risk factors for EP, the TVUS findings in each consultation, and the hCG levels were independent variables obtained from the electronic medical records. From these data, the pretest probability, based on the clinical presentation and risk factors, and the likelihood ratio for each variable were calculated for their use in the algorithm, yielding a posttest probability. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE(S): The accuracy of the online algorithm to identify cases of EP using clinical signs and symptoms, the presence of risk factors for EP, the TVUS findings in each consultation, and the hCG levels. The main outcome was EP, confirmed either by pathology report or by the presence of fetal heartbeat or gestational sac outside the uterine cavity. RESULT(S): Between January 1, 2009 and December 27, 2016, 2,495 women were analyzed, and the algorithm was applied to 2,185 of them. The incidence of EP was 8.5% (212/2,495); 310 women were excluded because they were submitted to surgery with decision thresholds <95%. The algorithm was applied to 2,185 women. Just one case remained inconclusive after 3 consultations, and it was considered as an error in prediction. The sensitivity, specificity, and accuracy values (95% confidence interval) of the algorithm were 98.9% (96.1%-99.8%), 98.9% (98.3%-99.2%), and 98.9% (98.3%-99.2%), respectively. CONCLUSION(S): The accuracy of the Bayesian algorithm to confirm or rule out EP is excellent. Online Nomogram https://docs.google.com/spreadsheets/d/1jStXlMBjbPyDf6_W0deKGKQLZHU5EFAe8rLhNVPuJuY/edit?usp=sharing.

Embarazo ectópico tubárico bilateral simultaneo, a propósito de una caso

Los embarazos ectópicos se producen en 1 de cada 150 gestaciones, siendo una entidad patológica frecuente, sin embargo el embarazo ectópico bilateral simultaneo es un evento muy raro. El presenta caso trata de una paciente de 34 años de edad derivada de centro de salud de área rural con el diagnostico preliminar de: embarazo de 8 semanas de gestación por FUM, además de hemorragia de la primera mitad del embarazo. Posterior a realizar un ultrasonografía se concluye con imágenes sugestivas de Gestación ectópica anexial derecha, realizándose una intervención quirúrgica de la paciente, encontrándose en ambos anexos tumoraciones negruzcas, confirmándose en el servicio de patología un embarazo ectópico tubárico bilateral simultaneo. El cuadro clínico es prácticamente el mismo que en el embarazo ectópico unilateral, sin embargo el diagnóstico del embarazo tubárico bilatera resulta de gran dificultad, el tratamiento laparoscópico de la sospecha de embarazo tubárico suele ser el método más frecuente para el diagnóstico de embarazo tubárico bilateral.

Ectopic pregnancies occur in 1 in 150 pregnancies, being a frequent pathological entity, however simultaneous bilateral ectopic pregnancy is a very rare event. The case presented deals with a 34-year-old patient, referred to a health center in a rural area with the preliminary diagnosis of: pregnancy of 8 weeks of gestation due to FUM, in addition to hemorrhage in the first half of the pregnancy. After performing an ultrasonography, images suggestive of a right adnexal ectopic pregnancy were concluded, performing a surgical intervention on the patient, finding blackish tumors in both annexes, confirming a simultaneous bilateral tubal ectopic pregnancy in the pathology service. The clinical picture is practically the same as in unilateral ectopic pregnancy, however the diagnosis of bilateral tubal pregnancy is very difficult, laparoscopic treatment of suspected tubal pregnancy is usually the most frequent method for the diagnosis of bilateral tubal pregnancy.