Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report.

BACKGROUND: Interstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively. CASE PRESENTATION: A 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22-23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7. CONCLUSION: Interstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Unusual presentation of late-stage ectopic tubal pregnancy (19 weeks' gestation): Case report and literature review.

Ectopic pregnancy is a medical condition in which a fertilized egg takes an unexpected detour away from the uterine cavity and the fallopian tube becomes a popular host, with the ampulla being the prime location. However, it can occur in other areas such as cervix, ovaries, or abdomen. The most common risk factors are pelvic inflammatory disease, previous pelvic or abdominal surgery, abnormal anatomy of genital organs, endometriosis, previous ectopic pregnancies, assisted reproductive technologies, endocrine disorders, and even the subtle influence of low-dose progestins from contraceptives. We will present a rare case of unrecognized late-stage tubal ectopic pregnancy. The following case report is of a 25-year-old Caucasian female patient (G2, P0) who presented to the emergency department with a 24-hour abdominal pain syndrome. The patient did not have a gynecological examination for this reason. During the examination, taking into account the clinical and ultrasound findings, a suspicion of pregnancy in a bicornuate uterus was raised, and an MRI of the pelvis was performed. MRI showed ectopic pregnancy in the left fallopian tube with a properly developed fetus that corresponded to a gestation of 19 weeks. An emergency laparotomy was performed and the left fallopian tube with the fetus was removed. The early and late course of recovery went smoothly. The patient was discharged after adequate clinical development.

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.

[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.

Large unruptured tubal pregnancy mimicking abdominal pregnancy.

Ectopic pregnancy accounts for 1-2% of all pregnancies. Ultrasound is the primary diagnostic tool to locate pregnancy outside the uterus and identify complications such as haemoperitoneum. In inconclusive cases, MRI is an adjunctive imaging modality offering more precise tissue differentiation and helpful to location identification. Presented is an unusual case of tubal pregnancy. The patient in her 30s, who was 14 weeks into her first pregnancy, had a suspected abdominal pregnancy. Both transabdominal ultrasound and an MRI indicated an ectopic pregnancy, likely originating from the right fallopian tube. A successful laparotomy and right salpingectomy were performed without complications. Rarely, as in this case, large unruptured and advanced tubal pregnancies can mimic an abdominal pregnancy, underscoring the importance of disease recognition and familiarity with uncommon image findings. An accurate diagnosis of pregnancy location is crucial for effective case management.

Abdominal ectopic pregnancy.

An ectopic pregnancy (EP) accounts for 1-2% of all pregnancies, of which 90% implant in the fallopian tube. An abdominal ectopic pregnancy (AEP) is defined as an ectopic pregnancy occurring when the gestational sac is implanted in the peritoneal cavity outside the uterine cavity or the fallopian tube. Implantation sites may include the omentum, peritoneum of the pelvic and abdominal cavity, the uterine surface and abdominal organs such as the spleen, intestine, liver and blood vessels. Primary abdominal pregnancy results from fertilisation of the ovum in the abdominal cavity and secondary occurs from an aborted or ruptured tubal pregnancy. It represents a very rare form of an EP, occurring in <1% of cases. At early gestations, it can be challenging to render the diagnosis, and it can be misdiagnosed as a tubal ectopic pregnancy. An AEP diagnosed >20 weeks' gestation, caused by the implantation of an abnormal placenta, is an important cause of maternal-fetal mortality due to the high risk of a major obstetric haemorrhage and coagulopathy following partial or total placental separation. Management options include surgical therapy (laparoscopy±laparotomy), medical therapy with intramuscular or intralesional methotrexate and/or intracardiac potassium chloride or a combination of medical and surgical management. The authors present the case of a multiparous woman in her early 30s presenting with heavy vaginal bleeding and abdominal pain at 8 weeks' gestation. Her beta-human chorionic gonadotropin (bHCG) was 5760 IU/L (range: 0-5), consistent with a viable pregnancy. Her transvaginal ultrasound scan suggested an ectopic pregnancy. Laparoscopy confirmed an AEP involving the pelvic lateral sidewall. Her postoperative 48-hour bHCG was 374 IU/L. Due to the rarity of this presentation, a high index of clinical suspicion correlated with the woman's symptoms; bHCG and ultrasound scan is required to establish the diagnosis to prevent morbidity and mortality.

Conservative Management of Heterotopic Pregnancy: A Case Report and Review of Literature.

BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and in an ectopic location, most commonly in the fallopian tube. The management of such cases is not clearly established. In the case of a desire to maintain an intrauterine pregnancy, the surgical procedure consisting of a salpingectomy or salpingostomy is the most common. Such a procedure is effective, but it involves potential complications typical of surgeries, so, in some cases, it seems reasonable to apply the expectant management. CASE REPORT A 31-year-old woman was admitted to the clinic due to pain in the right lower abdomen. An ultrasound examination revealed a gestational sac in the uterine cavity corresponding to 5 weeks of pregnancy with a yolk sac. A twin sac was found in the right fallopian tube. Due to the patient's mild symptoms, absence of bleeding into the peritoneal cavity, concerns about the safety of the embryo and the pregnant woman in case of surgery, conservative management was decided. On the 20th day, the patient was discharged from the clinic with a viable intrauterine pregnancy and a partially absorbed ectopic pregnancy. CONCLUSIONS In the case of an ectopic tubal pregnancy, if there are no symptoms of bleeding into the peritoneal cavity, it is possible to adopt a safe conservative approach with strict patient observation.

Missed Spontaneous Heterotopic Pregnancy: A Case Report of a Ruptured Tubal Pregnancy after Induced Abortion.

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Spontaneous bilateral tubal ectopic pregnancy preoperatively diagnosed by the ultrasound: a case report.

BACKGROUND: Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Therefore, reminding of this rare but emergent situation can be beneficial for both radiologists and gynecologists. Here we report a case of bilateral ectopic pregnancy, which was first diagnosed with ultrasound and was confirmed during laparoscopy. CASE PRESENTATION: A 34 years old woman complaining of light vaginal bleeding at 6 weeks of gestation by her last menstrual period presented to our institute. The serum ß-HCG levels were analyzed and followed during patient's admission. Unfortunately, serum levels weren't decreasing and blood test titration before surgery were as: 851,894,975 IU/l (checked daily and not every 48 h because of patient's status and being bilateral). There was no evidence of intrauterine pregnancy at the transvaginal ultrasound, but heterogeneous adnexal masses were seen at both adnexa, suspected of bilateral ectopic pregnancy. She underwent laparoscopic exploration, which confirmed the diagnosis. Bilateral salpingostomy was done to preserve fertility, and the patient's recovery was uneventful. CONCLUSIONS: Even with a unilateral report of ectopic pregnancy preoperatively in ultrasonography, surgeons should always be aware of the probability of bilateral ectopic pregnancies anytime facing susceptible cases, especially in patients with known risk factors. Also, it is an important reminder for radiologists to check both adnexa when facing a unilateral adnexal mass resembling ectopic pregnancy.

Tubal ectopic pregnancy in acute abdominal presentation: A case control analysis.

BACKGROUND: The aim of the study was to evaluate the demographic data, clinical findings, ectopic pregnancy (EP) localization (left or right-sided), and treatments versus clinical presentation of tubal pregnancies (TP) with or without acute abdomen. METHODS: Pregnants with a diagnosis of TP, selected for acute abdomen or not, were evaluated and compared, concerning EP local-ization (right/left), age, parity, symptoms (menstrual delay, vaginal bleeding, and groin pain), initial ß-hCG value, endometrial thickness, presence of rupture, and treatment type (methotrexate and surgery). RESULTS: On a total of 122 pregnants with TP, 32 showed acute abdomen, 45 had a TP located in the right tube and 32 in the left tube. In the acute abdomen group, parity, initial ß-hCG level, and endometrial thickness were greater than non-acute abdomen group. In addition to this, the frequency of bleeding complaints, right-sided TP, rupture, and need for surgery were higher, than to the non-acute abdomen group. The frequency of the previous EP and methotrexate treatment was higher in those with the left-sided TP compared to those with the right-sided TP. CONCLUSION: EP rate, in patients with TP who applied to the emergency department with acute abdominal symptoms, was mostly located in the right tube with greater frequency of salpingectomy in open surgery.

The Very First Romanian Unruptured 13-Weeks Gestation Tubal Ectopic Pregnancy.

Tubal ectopic pregnancies remain a challenging and life-threatening obstetric condition in the early stages that unavoidably lead to abortion or rupture, further reflected by the associated maternal mortality. Therefore, in the present case report, we report the experience of a 36-year-old woman who presented to our Emergency Department with a history of moderate hypogastric pain, mild vaginal bleeding, and bilateral mastalgia, symptoms that started 20 days ago after uterine curettage for a declarative eight-week pregnancy. On admission, a physical examination showed regular standard signs. The ultrasound examination revealed in the left abdominal flank a gestational sac with a live fetus corresponding to the gestational age of 13 weeks. Given the position of the gestational sac, we suspected a possible abdominal pregnancy. Independently on her human chorionic gonadotropin (hCG) of 33.980 mIU/mL and hemoglobin (Hb) of 13.4 g/dL, the exact location of the pregnancy following ultrasound was hard to establish. Magnetic resonance imaging (MRI) examination was requested, after which we suspected the diagnosis of ovarian pregnancy. Given the paraclinical and clinical context of the worsening of painful symptoms, we decided to perform an exploratory laparoscopy in the multidisciplinary team (digestive and vascular surgeon) that showed the existence of a tubal pregnancy.

Ruptured chronic ectopic pregnancy presenting with a negative urine pregnancy test.

An acute ectopic pregnancy is one of the most common gynaecological emergencies in clinical practice. The diagnosis is usually established by a combination of clinical examination findings, correlated with sonographic and laboratory results. However, a chronic ectopic pregnancy (CEP) may occur when the ectopically implanted gestation, mostly in the fallopian tubes, invades the underlying structures, causing protracted destruction at the site of implantation. Individuals may present with subacute or chronic abdominal pain, abnormal vaginal bleeding, amenorrhoea and a low bHCG. The correct diagnosis is often only established following laparoscopy or even histologically after the operation. The authors present the case of a woman in her 30 s presenting with severe right sided abdominal pain and a failing pregnancy at 10 weeks gestation. Her urine pregnancy test was negative, but her serum bHCG was 18 IU/L. A transvaginal ultrasound scan confirmed a ruptured right tubal ectopic pregnancy. A laparoscopic salpingectomy was performed. This case provides an important reminder that a CEP should always be considered in the differential diagnosis of women of reproductive age presenting with acute lower abdominal pain, despite a negative urine pregnancy test.

Serum vascular endothelial growth factor as a marker for tubal pregnancy.

OBJECTIVE: The objective of this study was to evaluate whether a single measurement of vascular endothelial growth factor could distinguish between intrauterine pregnancy and ectopic pregnancy and to correlate the levels of vascular endothelial growth factor with serum levels of progesterone andß-human chorionic gonadotropin in each subgroup. METHODS: Ninety patients with a positive human chorionic gonadotropin test and either abdominal pain or vaginal bleeding were selected; pregnancies were singletons, spontaneously conceived, 42-56 days of gestational age. All patients had a transvaginal ultrasound examination and were divided into three subgroups: abnormal intrauterine pregnancy, tubal pregnancy, and normal intrauterine pregnancy. Tubal pregnancies were surgically treated and histologically confirmed. Blood samples were collected for the determination of ß-human chorionic gonadotropin, progesterone, and vascular endothelial growth factor and their concentrations were compared in each subgroup. Receiver operating characteristic curve was calculated by comparing the subgroup of tubal pregnancy to the other groups. A Fisher discriminant function analysis was performed. The level of significance was 5%. RESULTS: One-way analysis of variance revealed a significant correlation between the different subgroups and ß-human chorionic gonadotropin, progesterone, and vascular endothelial growth factor serum levels (p<0.001). Vascular endothelial growth factor concentration was significantly higher for patients with tubal pregnancy than for other subgroups (p<0.05). ß-Human chorionic gonadotropin and progesterone levels were higher in the subgroup with normal intrauterine pregnancies compared with the subgroups with tubal and abnormal intrauterine pregnancies (p<0.05). Serum vascular endothelial growth factor level >188.7 ng/mL predicted tubal pregnancy with 96.7% sensitivity, 95.0% specificity, 90.6% positive predictive value, and 98.3% negative predictive value. CONCLUSIONS: Serum vascular endothelial growth factor could be a marker in discriminating intrauterine pregnancy from tubal pregnancy; its levels are increased in women with ectopic pregnancy compared with women with normal and abnormal intrauterine pregnancies.