Minimally Invasive Management and Diagnosis of Ectopic Splenic Pregnancy.

This report describes the case of a 32-year-old woman with ectopic pregnancy in the spleen, which was complicated by active bleeding. The patient complained of intermittent pain in her left side and lower abdomen that lasted several days. The serum beta-human chorionic gonadotropin (ß-hCG) was increased, but no intrauterine gestational sac was found via transvaginal sonography. A computed tomography (CT) examination revealed the presence of a heterogeneous structure in the left peritoneal cavity, inferior to the spleen; signs of active extravasation; and a large amount of hemorrhagic fluid in the pelvis. An angiography examination also showed slow active extravasation from a small artery that branches off at the lower pole of the spleen. Coil embolization was performed. Splenic ectopic pregnancy can be managed by minimally invasive methods in carefully selected patients.

Total laparoscopic wedge resection for an intramural ectopic pregnancy using an intraoperative ultrasound system: A case report.

Intramural pregnancy is a rare form of ectopic pregnancy, and the optimal treatment remains uncertain. We describe a 33-year-old woman (gravida 2, para 0) who visited our hospital with suspected ectopic pregnancy. The patient was asymptomatic and hemodynamically stable. Transvaginal ultrasonography revealed pregnancy at 6 weeks of gestation and a gestational sac and fetal heartbeat in the anterior muscular layer of the uterus, away from the endometrium. The fetal sac measured 26 mm. The serum human chorionic gonadotropin (hCG) level had increased to 27 655 mIU/mL. Accordingly, the patient was diagnosed with an intramural ectopic pregnancy and underwent total laparoscopic wedge resection using intraoperative ultrasonography. The postoperative course was uneventful, and she was discharged after 4 days. Her serum hCG level normalized at 26 days postoperatively. This case indicates that intraoperative laparoscopic ultrasonography seems viable for treating intramural pregnancies.

Differential Diagnostic Value of Two-dimensional Ultrasound Combined with Three-dimensional Ultrasound Imaging Technology for Cesarean Scar Pregnancy.

BACKGROUND: Cesarean scar pregnancy (CSP) refers to the phenomenon in which a fertilized egg implants and develops in the scar of the uterus in a woman with a history of cesarean section. OBJECTIVE: The study aimed to explore the differential diagnostic value of two-dimensional ultrasound (2D US) combined with three-dimensional ultrasound (3D US) for CSP. METHODS: Clinical data of 89 patients with CSP admitted to our hospital from January 2022 to January 2023 were retrospectively analyzed. Of them, 65 patients met the inclusion criteria. Patients underwent 2D US, 3D US, and combined 2D and 3D US imaging. Using the clinical pathological diagnosis as the "gold standard", the differential diagnostic value of 2D US, 3D US, and 2D US combined with 3D US for CSP was compared. RESULTS: The detection rate of CSP using a combined 2D US and 3D US was 98.46%, which was higher than 84.62% and 89.23% achieved with 2D US and 3D US alone, respectively (P<0.05). The pathological results showed that among 65 patients, CSP type I accounted for 24.62%, type II accounted for 55.38%, and type III accounted for 20.00%. The coincidence rate of 2D US combined with 3D US was 98.46%, which was higher than that of 2D US (83.08%) and 3D US 89.23%) alone (P<0.05). The accuracy, specificity, and sensitivity of 2D US combined with 3D US in diagnosing CSP were higher compared to the two methods alone (P<0.05). CONCLUSION: The combination of 2D US and 3D US can accurately detect and classify CSP, further improving diagnostic efficiency.

Plasma metabolomics for diagnostic biomarkers on ectopic pregnancy.

Metabolomics is a relatively novel omics tool to provide potential biomarkers for early diagnosis of the diseases and to insight the pathophysiology not having discussed ever before. In the present study, an ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS) was employed to the plasma samples of Group T1: Patients with ectopic pregnancy diagnosed using ultrasound, and followed-up with beta-hCG level (n = 40), Group T2: Patients with ectopic pregnancy diagnosed using ultrasound, underwent surgical treatment and confirmed using histopathology (n = 40), Group P: Healthy pregnant women (n = 40) in the first prenatal visit of pregnancy, Group C: Healthy volunteers (n = 40) scheduling a routine gynecological examination. Metabolite extraction was performed using 3 kDa pores - Amicon® Ultra 0.5 mL Centrifugal Filters. A gradient elution program (mobile phase composition was water and acetonitrile consisting of 0.1% formic acid) was applied using a C18 column (Agilent Zorbax 1.8 µM, 100 x 2.1 mm). Total analysis time was 25 min when the flow rate was 0.2 mL/min. The raw data was processed through XCMS - R program language edition where the optimum parameters detected using Isotopologue Parameter Optimization (IPO). The potential metabolites were identified using MetaboAnalyst 5.0 and finally 27 metabolites were evaluated to be proposed as potential biomarkers to be used for the diagnosis of ectopic pregnancy.

Predicting intraoperative hemorrhage during curettage treatment of cesarean scar pregnancy using free-breathing GRASP DCE-MRI.

OBJECTIVE: To explore the feasibility of the golden-angle radial sparse parallel (GRASP) dynamic magnetic resonance imaging (MRI) technique in predicting the intraoperative bleeding risk of scar pregnancy. METHODS: A total of 49 patients with cesarean scar pregnancy (CSP) who underwent curettage and GRASP-MRI imaging were retrospectively selected between January 2021 and July 2022. The pharmacokinetic parameters, including Wash-in, Wash-out, time to peck (TTP), initial area under the curve (iAUC), the transfer rate constant (Ktrans), constant flow rate (Kep), and volume of extracellular space (Ve), were calculated. The amount of intraoperative bleeding was recorded by a gynecologist who performed surgery, after which patients were divided into non-hemorrhage (blood loss ≤ 200 mL) and hemorrhage (blood loss > 200 mL) groups. The measured pharmacokinetic parameters were statistically compared using the t-test or Mann-Whitney U test with a significant level set to be p < 0.05. The receiver operating characteristic (ROC) curve was constructed, and the area under the curve (AUC) was calculated to evaluate each parameter's capability in intraoperative hemorrhage subgroup classification. RESULTS: Twenty patients had intraoperative hemorrhage (blood loss > 200 mL) during curettage. The hemorrhage group had larger Wash-in, iAUC, Ktrans, Ve, and shorter TTP than the non-hemorrhage group (all P > 0.05). Wash-in had the highest AUC value (0.90), while Ktrans had the lowest value (0.67). Wash-out and Kep were not significantly different between the two groups. CONCLUSION: GRASP DCE-MRI has the potential to forecast intraoperative hemorrhage during curettage treatment of CSP, with Wash-in exhibiting the highest predictive performance. This data holds promise for advancing personalized treatment. However, further study is required to compare its effectiveness with other risk factors identified through anatomical MRI and ultrasound.

[Rudimentary horn pregnancy: clinical analysis of 12 cases and literature review].

Objective: To investigate the clinical characteristics, treatments and fertility recovery of rudimentary horn pregnancy (RHP). Methods: The clinical data of 12 cases with RHP diagnosed and treated in Peking University Third Hospital from January 1, 2010 to December 31, 2022 were retrospectively analyzed. Clinical informations, diagnosis and treatments of RHP and the pregnancy status after surgery were analyzed. Results: The median age of 12 RHP patients was 29 years (range: 24-37 years). Eight cases of pregnancy in residual horn of uterus occurred in type Ⅰ residual horn of uterus, 4 cases occurred in type Ⅱ residual horn of uterus; among which 5 cases were misdiagnosed by ultrasound before surgery. All patients underwent excision of residual horn of uterus and affected salpingectomy. After surgery, 9 patients expected future pregnancy, and 3 cases of natural pregnancy, 2 cases of successful pregnancy through assisted reproductive technology. Four pregnancies resulted in live birth with cesarean section, and 1 case resulted in spontaneous abortion during the first trimester of pregnancy. No uterine rupture or ectopic pregnancy occurred in subsequent pregnancies. Conclusions: Ultrasonography could aid early diagnosis of RHP while misdiagnosis occurred in certain cases. Thus, a comprehensive judgment and decision ought to be made based on medical history, physical examination and assisted examination. Surgical exploration is necessary for diagnosis and treatment of RHP. For infertile patients, assisted reproductive technology should be applied when necessary. Caution to prevent the occurrence of pregnancy complications such as uterine rupture, and application of cesarean section to terminate pregnancy are recommended.

Rare case of haemoperitoneum secondary to a ruptured ovarian ectopic pregnancy superimposed by a bleeding corpus luteum cyst.

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run.

Evaluation of Clinical Efficacy of Contrast-Enhanced Ultrasound in the Diagnosis of Ectopic Tubal Pregnancy.

Objective: To explore whether contrast-enhanced ultrasound (CEUS) can improve tubal ectopic pregnancy detection rate, tubal dilation, tubal hematoma, and gestational sac. Methods: This retrospective study included 34 patients with suspected ectopic pregnancy who underwent contrast-enhanced ultrasound at Dongzhimen Hospital of Beijing University of Chinese Medicine between March 2021 and September 2016. Of these, 27 patients were confirmed to have tubal pregnancy by laparoscopic surgery and histopathology. Four ultrasound physicians (2 experts and 2 non-experts) conducted a retrospective analysis of conventional color Doppler ultrasound and the combination of conventional color Doppler ultrasound with contrast-enhanced ultrasound (color Doppler ultrasound + CEUS). They analyzed the differences in confidence levels and reproducibility in identifying tubal dilation, tubal hematoma, and gestational sac implantation sites. Additionally, the characteristic features of ectopic pregnancy on contrast-enhanced ultrasound were summarized, including gestational sac morphology, triple ring sign, enhancement patterns (branching or punctate), tubal dilation (with or without hematoma), contrast enhancement of tubal walls, and presence of free fluid. Results: In the expert group, the correct identification rate of the gestational sac implantation site on ultrasound images increased from 13/34 (38.2%) with conventional color Doppler ultrasound to 20/34 (58.8%) with color Doppler ultrasound + CEUS, the differences were statistically significant (38.2% vs. 58.8%, P = .039). The correct identification rate of tubal dilation increased from 6/34 (17.7%) to 25/34 (73.5%) (P = .001), and the correct identification rate of tubal hematoma increased from 3/34 (8.8%) to 17/34 (50.0%) with color Doppler ultrasound + CEUS (P < .001). In the non-expert group, the correct identification rate of the gestational sac implantation site increased from 8/24 (23.5%) with conventional ultrasound to 19/34 (55.9%) with ultrasound + CEUS (P = .003). The correct identification rate of tubal dilation increased from 6/34 (17.7%) to 23/34 (67.7%) (P < .001), and the correct identification rate of tubal hematoma increased from 3/34 (8.82%) to 12/34 (35.3%) with color Doppler ultrasound + CEUS (P = .012). Conclusion: The analysis of contrast-enhanced ultrasound images provides characteristic features and diagnostic points for tubal ectopic pregnancy, including gestational sac, thick ring sign, tubal dilation, and tubal dilation with hematoma. This approach improves the accuracy of partial pregnancy of unknown location (PUL) diagnosis and reduces the technical dependence on ultrasound personnel.

Updating M6 pregnancy of unknown location risk-prediction model including evaluation of clinical factors.

OBJECTIVES: Ectopic pregnancy (EP) is a major high-risk outcome following a pregnancy of unknown location (PUL) classification. Biochemical markers are used to triage PUL as high vs low risk to guide appropriate follow-up. The M6 model is currently the best risk-prediction model. We aimed to update the M6 model and evaluate whether performance can be improved by including clinical factors. METHODS: This prospective cohort study recruited consecutive PUL between January 2015 and January 2017 at eight units (Phase 1), with two centers continuing recruitment between January 2017 and March 2021 (Phase 2). Serum samples were collected routinely and sent for ß-human chorionic gonadotropin (ß-hCG) and progesterone measurement. Clinical factors recorded were maternal age, pain score, bleeding score and history of EP. Based on transvaginal ultrasonography and/or biochemical confirmation during follow-up, PUL were classified subsequently as failed PUL (FPUL), intrauterine pregnancy (IUP) or EP (including persistent PUL (PPUL)). The M6 models with (M6P ) and without (M6NP ) progesterone were refitted and extended with clinical factors. Model validation was performed using internal-external cross-validation (IECV) (Phase 1) and temporal external validation (EV) (Phase 2). Missing values were handled using multiple imputation. RESULTS: Overall, 5473 PUL were recruited over both phases. A total of 709 PUL were excluded because maternal age was < 16 years or initial ß-hCG was ≤ 25 IU/L, leaving 4764 (87%) PUL for analysis (2894 in Phase 1 and 1870 in Phase 2). For the refitted M6P model, the area under the receiver-operating-characteristics curve (AUC) for EP/PPUL vs IUP/FPUL was 0.89 for IECV and 0.84-0.88 for EV, with respective sensitivities of 94% and 92-93%. For the refitted M6NP model, the AUCs were 0.85 for IECV and 0.82-0.86 for EV, with respective sensitivities of 92% and 93-94%. Calibration performance was good overall, but with heterogeneity between centers. Net Benefit confirmed clinical utility. The change in AUC when M6P was extended to include maternal age, bleeding score and history of EP was between -0.02 and 0.01, depending on center and phase. The corresponding change in AUC when M6NP was extended was between -0.01 and 0.03. At the 5% threshold to define high risk of EP/PPUL, extending M6P altered sensitivity by -0.02 to -0.01, specificity by 0.03 to 0.04 and Net Benefit by -0.005 to 0.006. Extending M6NP altered sensitivity by -0.03 to -0.01, specificity by 0.05 to 0.07 and Net Benefit by -0.005 to 0.006. CONCLUSIONS: The updated M6 model offers accurate diagnostic performance, with excellent sensitivity for EP. Adding clinical factors to the model improved performance in some centers, especially when progesterone levels were not suitable or unavailable. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ruptured primary omental ectopic pregnancy during the first trimester.

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Clinical value of ultrasonic indicators in predicting the outcome of caesarean scar pregnancy after pregnancy termination.

BACKGROUND: To investigate the predictive value of ultrasound indicators in early pregnancy for the outcome of caesarean scar pregnancy (CSP) after pregnancy termination. METHODS: This study retrospectively analysed the ultrasound images of 98 CSP patients who underwent transabdominal ultrasound-guided hysteroscopic curettage during early pregnancy at Changsha Hospital for Maternal and Child Health Care between January 2017 and October 2021. Patients were equally divided into a case group and a control group. The case group included 49 CSP patients with postoperative complications, such as intraoperative blood loss ≥ 200 ml or retained products of conception (RPOC). The remaining 49 CSP patients, with similar age and gestational age and with good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, were included in the control group. CSP was classified into three types according to the location of the gestational sac (GS) relative to the uterine cavity line (UCL) and serosal contour. Differences in ultrasound indicators between the case and control group were compared. RESULTS: There were significant differences between the case and control groups in the mean gestational sac diameter (MGSD), residual myometrium thickness (RMT) between the GS and the bladder, blood flow around the GS at the site of the previous caesarean incision, and types of CSP (P < 0.05). The rs of each ultrasound indicator were as follows: 0.258, -0.485, 0.369, 0.350. The optimal threshold for predicting good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, by receiver operating characteristic (ROC) curve analysis of the RMT was 2.3 mm. CONCLUSION: Our findings show that the RMT, blood flow around the GS at the site of the previous caesarean incision, and types of CSP have a low correlation with postoperative complications, such as intraoperative blood loss ≥ 200 ml or RPOC, of early pregnancy termination in patients with CSP. To some extent, this study may be helpful for clinical prognostic prediction of patients with CSP and formulation of treatment strategies. Given the low correlation between these three indicators and postoperative complications, further studies are needed to identify indicators that can better reflect the postoperative outcomes of CSP patients.

Clinical implications of a cesarean scar pregnancy sonographic evaluation and reporting system.

OBJECTIVES: Recently, a new standardized sonographic evaluation system for cesarean scar pregnancies (CSP) was published. We aimed to evaluate the clinical outcomes of CSP cases according to the new sonographic evaluation and reporting system. STUDY DESIGN: A retrospective study conducted at a single tertiary center. All CSPs between 1/2011 and 4/2022 were included. Cases were evaluated by expert sonographers and classified into three categories: 1) CSP in which the largest part of the gestational sac (GS) protrudes towards the uterine cavity; 2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and 3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus.Baseline characteristics, management and outcomes were compared between the three categories. RESULTS: Overall, 55 patients were diagnosed with CSP during the study period; 10 (18.1 %) type 1, 31 (56.3 %) type 2, and 14 (25.4 %) type 3. Baseline characteristics were similar among groups. Compared with type 2 and 3, patients diagnosed with CSP type 1 received less methotrexate treatment [83.9 % and 78.6 % vs. 40.0 %, respectively, p = 0.020]. The rates of need for invasive procedures, urgent procedures, major bleeding, length of hospitalization, and subsequent pregnancies were similar between groups. CONCLUSIONS: No clinically significant differences were found between groups divided by the new standardized sonographic evaluation and reporting system for CSP in pregnancy characteristics, management, and subsequent pregnancy outcomes. Further investigation is required to enable informed management of CSP based on the new sonographic reporting system.

Ectopic pregnancy adjacent to iliac vessels managed successfully by minimally invasive treatment using local methotrexate injection: An extremely rare case and literature review.

A case report of successfully treated retroperitoneal ectopic pregnancy (REP) is presented. A 36-year-old woman, gravida 3, para 2, was admitted to hospital for suspected ectopic pregnancy with light vaginal bleeding and mild abdominal pain for 3 days at 45 days of gestation by the last menstrual period.Multiple transvaginal ultrasonography and two times laparoscopic probes led to the diagnosis of REP located to the iliac blood vessels closely. Eventually the patient was cured with the treatment using local methotrexate injection under real-time ultrasound guidance and systemic methotrexate administration. We also summarized another 31 cases of REP to further understand this disease, sharing them to arouse clinical attention for the diagnosis and treatment of REP timely.

Early diagnosis of caesarean scar pregnancy by ultrasound - a novel, simple and rapid clinical classification scoring system.

AIM: In the recent years, with the increase in the caesarean section rate, the incidence of caesarean scar pregnancy (CSP) has shown a significant upwards trend. We propose a novel, simple and rapid clinical and ultrasound (US) classification scoring system to assist in the early diagnosis of CSP. MATERIAL AND METHODS: A total of 385 patients with CSP were included in the study. All patients were given a comprehensive score, iincluding clinical data (whether HCG is consistent with gestational age and vaginal bleeding) and US findings (linea a and b, gestational sac morphology, the presence of primitive cardiac tube beat, and color Doppler aspect). The scores were analysed by ROC curve analysis, and sensitivity and specificity were calculated. RESULTS: A score of 4 has a specificity of 91.7% and a sensitivity of 95.6% in diagnose CSP. The area under the ROC curve was 0.973. CONCLUSION: This scoring system may be a reliable tool for the early diagnosis of CSP and has the characteristics of being simple and rapid. For patients with a total score of ≥4 points, CSP is suggested, and early clinical treatment can be carried out, while patients with a score of less than 4 points can temporarily retain pregnancy and be closely followed up.

Prognostic factors for spontaneous resolution of an ectopic pregnancy.

OBJECTIVE: To identify factors that can accurately predict the spontaneous resolution of an ectopic pregnancy. STUDY DESIGN: This retrospective cohort analysis was conducted in the Department of Gynecology of a tertiary, university-affiliated medical center. Patients admitted to the center from January 2015 to July 2022 with a tubal ectopic pregnancy who met the criteria for expectant management were included. Beta-human chorionic gonadotropin (ß-hCG) levels were assessed at admission and at subsequent 24-hour intervals. Patients with declining levels were discharged for routine ambulatory ß-hCG follow-up until levels became undetectable. Patients who achieved a successful outcome were designated as the "spontaneous resolution group," while patients who underwent further hospitalization for methotrexate or surgery constituted the" failure group". Demographic, clinical, laboratory, and ultrasound parameters collected at first admission were compared between groups. RESULTS: Among the initial group of 210 eligible patients, 7 were lost to follow-up, 161 achieved spontaneous resolution, and 42 were readmitted for active intervention. Multivariate logistic regression analysis revealed that the last ß-hCG level before discharge (last ß-hCG) and the ratio between ß-hCG at discharge to ß-hCG at admission were the only independent parameters to predict outcomes. Patients with ß-hCG < 650 IU/L at discharge and a decline of 50% or more in ß-hCG level during hospitalization, had a 97% success rate with expectant management. Patients with ß-hCG discharge levels ≥ 1,000 IU/L had a 50% chance of success, regardless of whether their ß-hCG levels had declined. For all other patients, a 76% success rate was found. CONCLUSION: Short-term, serial ß-hCG follow-up at the initial presentation can help predict the spontaneous resolution of an ectopic pregnancy.