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Recurrent ectopic pregnancy case presentation - OBGYN

VIEWS: 31 PAGES: 70

									AKRAM ABD ELGHANY
MD.OBS.&GYN.
ALAZHAR UNIVERSITY EGYPT
Consultant obs.& gyn.
A 33-year-multipara presented with
 missed period with IUCD.
 regular menstrual cycle (28-30
  days).
 Her last menstruation had been
  from March 27 ,2010 for 4 days.
 Urinary pregnancy test was
  positive on 1 May 2010 repeated
  many times over 2weeks.
 On  MAY 18, 2010 ,She presented with
  lower abdominal pain and irregular
  vaginal bleeding for 2 weeks.
 positive pregnancy test.
 vital parameters were normal.
 abdominal examination revealed
  rigidity suprapubic tenderness and
  rebound tenderness .
 Pelvic examination tender fornices
  and tender cervical motion.
 Transvaginal ultrasound (TVS)
  showed
 AVF bulky empty uterus.
 endometrium trilamner 6mm.
 LT. complex heterogenous mass
  50x40 mm beside left ovary.
 RT. adnexa is free.
 moderate amount of fluid in the
    pouch of Douglas.
 The  patient was counselled
  concerning the possibility of an
  ectopic pregnancy and informed
  consent for
 laparoscopic exploration,with the
  possible need for salpingostomy or
  salpingectomy was obtained.
     At laparoscopy
 pelvic collection of blood.
 LT .tube ruptured in mesosalpinex
 forming a hemorrhagic mass 5x4cm .
 Blood escape from LT.fimberia.
 The RT. adnexa was free .
 The left mesosalpinex was then
 found to contain a mass 5cm
 consistent with an ectopic pregnancy.
 salpingectomy  of the LT. tube produced
  products resembling hemorrhagic tissue
  typically found with ectopic pregnancies.
 There were no complications from the
  surgery and the patient recovered well.
The products of conception and the LT. tube
  were removed through a 10 mm RT. Trocar.
 She visited my clinic 4 times thereafter
  with no post operative complains except
  umbilical wound infection.
On 20 June 2010 she visited
 my clinic with 5 weeks
 amenorrhea and positive home
 pregnancy test.
there were no complain.
general ,abdominal and pelvic
 examination were normal.
TVS diagnosed
 RT. Adnexal mass 20 mm x 15
 mm.
 gestational sac 8mm.
 yolk sac is present.
 no embryonic echo.
 minimal fluid in DP.
 LT.adnexa is free.
  serum B,hCG was 15,000 IU/L.
 RT. recent new 5 weeks undisturbed
  ectopic pregnancy was diagnosed.
 the patient refused conservative
  management to save the RT. Tube.
 RT. salpingectomy was done through
  laparotomy in another clinic on 22
  June 2010.
 No attemps were made to save the last
  tube.
 No blood transfusion.
 This seems to be a rare, atypical case
  of ectopic pregnancies in two
  consecutive menstrual cycles.
 There is a great rarity of this event.
 With the incidence of ectopic
  pregnancy increasing, bizarre cases
  (for example, heterotopic, bilateral
  or consecutive) will be seen more
  often.      Irvine,etal.1999
 Reported the first case of ectopic
  pregnanccies in two consecutive menstrual
  cycles.
 A 28-year-old multigravid woman reported
  six weeks of amenorrhoea and two days of
  abdominal pain and vaginal bleeding.
 On examination she was
  haemodynamically stable.
 the abdomen was tender, and the uterus
  was bulky with tenderness in the left
  fornix.
A  urinary pregnancy test was positive.
 At laparotomy a small leaking left
  distal ectopic pregnancy was seen and
  a left partial salpingectomy was
  performed.
 the right adnexa was noted to be
  normal.
 She recovered uneventfully and was
  discharged home on the fifth
  postoperative day.
 At her eight-week follow-up visit she
  complained of right-sided abdominal pain.
 on vaginal examination she was tender in
  the right adnexa.
 On admission the differential diagnosis was
  judged to be pelvic inflammatory disease,
  urinary tract infection or appendicitis.
 A transabdominal scan showed a normal-
  sized uterus with a 2 cm ill-defined echo-
  poor area by the right ovary, thought to be
  a small collection of fluid.
 She was afebrile and clinically stable.
 Treatment was started with
 intravenous erythromycin 200mg
 three times daily and blood
 samples were taken six days apart
 for measurement of beta human
 chorionic gonadotropin, which was
 120 U/L rising to 170 U/L.
 Her  abdominal pain settled and she was
  clinically well but, in the absence of a
  definitive diagnosis.
 laparoscopy was done on day seven.
 She had a haemoperitoneum of 200 mL and
  a right distal leaking ectopic pregnancy.
 A right partial salpingectomy was
  performed.
 Histological examination of both fallopian
  tubes revealed chorionic villi, confirming
  the ectopic pregnancies.
reported  a case of bilateral
 chronic and acute tubal
 pregnancies following failed
 treatment with methotrexate
 for a previous ectopic
 pregnancy.
Reported evidence in support of
 superfetation in a patient who
 had an ongoing ectopic
 pregnancy. The patient had a
 documented rise in mid-cycle
 basal body temperature,
 suggesting ovulation occurred
 while she carried a tubal
 pregnancy.
encountered  a unique case
of combined pregnancy in
which an intrauterine
pregnancy was established
following a spontaneous
ovulation occurring whilst
the woman had another
ectopic pregnancy.
 S,b,HCG   1024 IU/L .
 Pelvic examination and
  ultrasonography indicated an
  extrauterine pregnancy, which was
  confirmed by laparotomy and
  histological identification of
  trophoblast cells.
 HCG concentration markedly
  decreased after the operation.
The HCG level increased again on the
fifth postoperative day,and
a gestational sac (11 mm) was
identified in the uterine cavity on the
11th post-operative day, indicating
that this intrauterine pregnancy was
established following spontaneous
ovulation which occurred before the
removal of the extrauterine
pregnancy.
This case indicates that a
 combined pregnancy can
 occur not only after
 simultaneous multiple
 ovulations but also after the
 separate spontaneous
 ovulations.
Reported Bilateral tubal pregnancies
 in the absence of preceding
 induction of ovulation are an
 extremely unusual occurrence and
 are thought to represent the rarest
 form of extrauterine pregnancy.
 More common are twin pregnancies
 in the same tube and heterotopic
 pregnancies.
A  25-year-old gravida 3, para 0 woman was
  an approximate gestational age of 9 weeks
  and 2 days.
 Presented with vaginal bleeding and
  intermittent lower abdominal cramping.
 The patient was hemodynamically stable.
 The initial level of serum hCG was 24,242
  IU/L.
 A transvaginal pelvic ultrasound
  examination revealed an empty uterus
  with a right adnexal mass measuring 4.3 x
  2.3 cm.
  bilateral tubal pregnancies diagnosed
  intraoperatively.
 The pathology report confirmed the
  diagnosis of spontaneous bilateral tubal
  pregnancies,
 the tissue removed from the right tube
  showing blood clot admixed with
  chorionic villi.
 The tissue obtained from the left tube
  showed multiple fragments of fetal
  tissue, including the vertebral column,
  neurological structures, liver, intestine,
  umbilical cord, and chorionic villi.
 Reported  a 31-year-old woman with a
  positive pregnancy test.
 a transvaginal ultrasound scan result that was
  suggestive of a right tubal ectopic pregnancy.
 a laparoscopy, showed bilateral
  hematosalpinx.
 In the presence of active bleeding and
  deteriorating hemodynamic status of the
  patient, a minilaparotomy was performed
  that revealed a right-sided hematosalpinx
  and a left-sided ectopic gestation.
 described  a unique case of
 concurrent chronic and acute
 ectopic pregnancies in an
 ipsilateral tube.
 A 33-year-old woman presented
 with symptoms suggestive of
 miscarriage that resolved on
 conservative management,
 resulting to normal ßhCG level.
 she was readmitted 5 weeks later with
  vaginal spotting, right iliac fossa pain .
 TVS revealed an empty uterus, no signs
  of retained products of conception and
  a small 1.9x1.6x1.3cm mass medial to
  right ovary. ßhCG was 34 U/L.
 A diagnosis of pregnancy of unknown
  location was made and she was managed
  conservatively.
 Four weeks later the patient presented once again
  with vaginal bleeding and a positive pregnancy
  test.
 TVS showed a right adnexal mass (1.3x1.5x1.6
  cm) and some free fluid in pelvis.
 ßhCG was highly elevated at 9661 U/L.
 A diagnosis of ectopic pregnancy was made and
  the patient underwent laparoscopic
  salpingectomy.
 Histopathological examination showed two ectopic
  pregnancies within the same tube; an older
  (chronic) ectopic positioned within proximal end
  of the tube and a more recent acute one at the
  distal end.
 Histopathological examination of the removed tube
  showed “two separate lesions manifesting two
  ectopic pregnancies; an older (chronic) one
  positioned proximally and more recent one at the
  distal end.
 Sections of the 6 mm lesion towards the uterine
  proximal end of the fallopian tube showed
  characteristic features of chronic ectopic
  pregnancy: a fibrinous nodule with evidence of
  fresh and old haemorrhage. Within this; the "ghost"
  outlines of a few necrotic chorionic villi were
  identified” .
 The other lesion noted at the distal end of the
  fallopian tube close to the fimbria was a viable
  decidua, and unvascularised small chorionic villi .
 Milingos,etal. reported the case of a
 patient who had three consecutive ectopic
 pregnancies on the ipsilateral side after
 natural conception and was treated
 surgically in each case with partial
 salpingectomy, removal of tubal stump, and
 resection of the uterine cornua,
 respectively. The contralateral normal tube
 was resected at the time of last operation.
                     Obstet Gynecol. 2008
 Clinically, ovulation has been
  reported to occur 2 weeks after
 artificial abortion of intrauterine
  pregnancy .
             Boyd and Holmstrom,1972
 operation for ectopic pregnancy .
                   Spirtos et al,1987
 50%  demonstrated ovulation before day 14
  after mangement of chronic ectopic
  pregnancy. (serum progesterone at least 3
  ng/mL on day21)
 the onset of ovulation is missed in
  approximately three-quarters of cases and
  hence the possibility of further pregnancy.
 contraception should be introduced
  immediately after surgery, if further
  pregnancy is unwanted or contraindicated.
            Spirtos,et al.Obstet Gynecol 1987
 reported that the administration of
 exogenous HCG for ovulation induction
 or luteal support lowered the FSH in
 the late luteal phase, and increased
 the size of persistent follicles in the
 late luteal phase and the follicular
 phase of the next cycle.
 They speculated that the trigger of
 the second ovulation was endogenous
 HCG.
  There is a wide range in the normal
  hCG level at each week of pregnancy
 5,000 to 150,000 IU/L.
                        Silva et al, 2006 .
 Quantitative tests are not useful for
  estimating gestational age because of
  the wide range in hCG levels at any
  given point in pregnancy .
          Seeber, Obstet Gynecol 2006.
 The  hCG concentration rises at a much
  slower rate in most, but not all, ectopic
  and nonviable intrauterine pregnancies.
 only 21 percent of ectopic pregnancies
  were associated with hCG levels that
  followed the minimum doubling time of a
  viable intrauterine pregnancy (defined in
  this series as ≥ 53 percent increase over
  two days).     Silva et al, 2006.
 The serum B,HCG of ectopic pregnancy
  may be very high as in viable undisturbed
  ectopic , twin ectopic , vesicular mole
  with ectopic and bilateral tubal ectopic.
A falling hCG concentration is
 most consistent with a failed
 pregnancy eg,
arrested pregnancy.
anembryonic pregnancy.
 tubal abortion, spontaneously
   resolving ectopic pregnancy.
 complete or incomplete
   abortion.
  The earliest sonographic sign
 of an intrauterine pregnancy is
 the presence of
A true gestational sac, which
 has double echogenic rings
 surrounding the sac.
        Bradley, Radiology 1982.
    the gestational sac is usually visible
  at 4.5 to 5 weeks of gestation.
 an embryo with cardiac activity is
  first detected at 5.5 to 6 weeks.
 Pseudosacs are often found in
  association with ectopic pregnancy.
  They tend to be located in the middle
  of the uterine cavity rather than
  embedded in the decidua, and
  conform to contour of the cavity.
 Visualization of an extrauterine
 gestational sac containing a yolk sac or
 embryo is diagnostic of ectopic
 pregnancy, but this combination of
 findings is detected in only a small
 proportion of cases 20% .
 in expert ultrasound units,
 abnormalities suggestive of the
 diagnosis will be identified in 90
 percent of ectopic pregnancies .
        Condous,etal. Hum Reprod 2005.
Acomplex adnexal mass in the
presence of a positive pregnancy
test and empty uterus is highly
suggestive of an extrauterine
gestation and is the most
common sonographic
abnormality.
 the sensitivity of 73.9 percent
  (95% CI 65.1– 81.6),
 a specificity of 99.9 percent (95%
  CI 99.8– 100),
 a positive predictive value of 96.7
  percent (95% CI 90.7– 99.3),
 a negative predictive value of 99.4
  percent (95% CI: 99.2– 99.6).
         Kirk,etal. Hum Reprod 2007.
 TVS does not reveal an
 intrauterine pregnancy and
 shows a complex adnexal mass,
 an extrauterine pregnancy is
 almost certain.
The diagnosis of ectopic
 pregnancy is less certain if no
 complex adnexal mass can be
 visualized.
 repeat the TVS examination
 and hCG concentration two
 days later.
 If an intrauterine pregnancy
 is still not observed on TVS,
 then the pregnancy is
 abnormal.
  A serum hCG concentration less
  than 1500 IU/L should be followed
  by repetition of hCG in three days
  to follow the rate of rise.
 HCG concentrations usually double
  every 1.4 to two days until six to
  seven weeks of gestation in viable
  intrauterine pregnancies (and in
  some ectopic gestations).
Anormally rising hCG
concentration should be
evaluated with TVS when the
hCG reaches the
discriminatory zone. At that
time, an intrauterine
pregnancy or an ectopic
pregnancy can be diagnosed.
 Ifthe hCG concentration does not
  double over 72 hours then the
  pregnancy is abnormal (an ectopic
  gestation or failed intrauterine
  pregnancy).
 The clinician can be reasonably
  certain that a normal intrauterine
  pregnancy is not present.
 If an adnexal mass is visualized on
  TVS, then medical or surgical
  treatment is administered for a
  presumed ectopic pregnancy.
Ifan adnexal mass is not
 visualized, some clinicians
 administer methotrexate and
 others perform curettage to
 determine the type of nonviable
 pregnancy and thereby avoid
 medical therapy of nonviable
 intrauterine pregnancies .
  Seeber,etal.Obstet Gynecol 2006.
Previous  ectopic
 pregnancy.recurrence is 15%
Tubal pathology and surgery.
chronic salpingitis, is observed
 in up to 90 percent of ectopic
 pregnancies.
 Intrauterine contraception
 isa problematic diagnosis.
 The clinical presentation can be mild, with
  absent or subtle symptoms.
 The high incidence of negative pregnancy
  tests or very low ßhCG, the poor
  specificity of sonographic patterns can be
  misleading.
 The correct diagnosis can only be
  established at surgery or following
  histopathological examination of the
  resected specimen.
 The  presentation of chronic ectopic
  pregnancy as an inflammatory mass
  can cause problems in differential
  diagnosis.
 The involution of the trophoblast
  may allow the menstrual cycles to
  re-establish and the convoluted,
  blood- filled tube often involving the
  ipsilateral ovary may simulate
  tumour or an endometriotic mass
 The  classic symptoms of ectopic
  pregnancy are :
    Abdominal pain 99%.
    Amenorrhea 74%.
    Vaginal bleeding 54%.
 these symptoms are not diagnostic of
  ectopic pregnancy; they are the same
  as those associated with threatened
  abortion, which is far more common.
  dramatically moved away from a
  primarily surgical approach .
  Yao,etal.Fertil Steril 1997.
 Currently, most women with unruptured
  ectopic pregnancies are treated with
  methotrexate.
 some women undergo surgical therapy
  by choice or by necessity, if they are
  not good candidates for medical
  therapy.
The  extent of surgical management
 would depend on the size of the
 mass, involvement of adjacent
 organs and the reproductive
 history of the patient. This might
 vary from conservative surgical
 excision of the mass to salpingo-
 oophorectomy or even more
 extensive surgery.
 Failure to diagnose ectopic pregnancy
  before tubal rupture limits the treatment
  options and increases maternal morbidity
  and mortality.
 four factors that increased the risk of
  rupture when an ectopic pregnancy was
  suspected:
 (1) never having used contraception,
 (2) history of tubal damage and infertility,
 (3) induction of ovulation, and
 (4) high level of HCG (at least 10,000 IU/L) .
 is not recommended.
 It is possible that some ectopics will
  resolve spontaneously.
 The initial titer of hCG and the trend on
  serial monitoring are both predictors of
  success for expectant management.
 The higher the initial concentration, the
  more likely it is that expectant treatment
  will fail.
 If the initial concentration is <1000
  mIU/mL, expectant management can be
  successful in 88% of cases
 Hemodynamic instability.
 Impending rupture of ectopic .
 mass Contraindications to use of methotrexate.
 Coexisting intrauterine pregnancy .
 Not able or willing to comply with medical
  therapy posttreatment follow-up.
 Lack of timely access to a medical institution
  for management of tubal rupture .
 Desire for permanent contraception .
 Known tubal disease with planned in vitro
  fertilization for future pregnancy.
 Failed medical therapy
In hemodynamically stable
 women, surgical intervention
 should only be considered if a
 transvaginal ultrasound
 examination (TVS) clearly shows
 a tubal ectopic pregnancy or an
 adnexal mass suggestive of
 ectopic pregnancy.
   no abnormality is imaged sonographically,
 If
 there is a high probability that an ectopic
 pregnancy will not be visualized or
 palpated at surgery.
 these women should be managed
 conservatively with either medical therapy
 or expectant management.
 A repeat ultrasound examination after a
 few days may visualize an abnormality,
 thus enabling a surgical procedure, if this
 option is desired.
 less time for resolution of
 the ectopic pregnancy.
avoidance of the need for
 prolonged monitoring.
 Operative morbidity is similar for both
  procedures.
 Salpingectomy does not appear to compromise
  the rate of subsequent intrauterine pregnancy
  in women whose contralateral fallopian tube
  appears to be normal and avoids the
  complication of persistent or recurrent ectopic
  pregnancy in the same tube.
 reproductive outcome reflect tubal status at
  surgery, rather than the choice of surgical
  procedure. Dubuisson, et al.Hum Reprod 1996.
 In these situations, there is a low probability of
  future normal tubal function and the risk of
  persistent or recurrent tubal problems is high.
   We perform salpingectomy, instead of
  salpingostomy in the following situations:
 Uncontrolled bleeding from the implantation
  site.
 Recurrent ectopic pregnancy in the same tube.
 Severely damaged tube.
 Large tubal pregnancy (ie, greater than 5 cm).
 Women who have completed childbearing.
hemodynamically    stable.
reasonable probability of
 future normal tubal
 function in the affected
 tube.
 Laparoscopic   surgery is the standard
  surgical approach for ectopic pregnancy.
 Most ectopic pregnancies, even in the
  presence of hemoperitoneum, heterotopic
  pregnancy, and interstitial pregnancy, can
  be treated by a laparoscopic procedure.
 However, the surgical approach depends
  upon the experience and judgment of the
  surgeon and the anesthetist, and the
  clinical status of the patient.
 The incidence 4 to 15 percent.
 higher after laparoscopic salpingostomy than after
  open procedures.

The serum beta-hCG concentration on the first
 postoperative day generally declined by more than 50
 percent of the preoperative value .
 In series of 147 women treated conservatively for
 ectopic pregnancy, there were no cases of persistent
 ectopic pregnancy when the postoperative beta-hCG
 on day 1 fell by more than 76 percent .
            Spandorfer, etal. Fertil Steril 1997.
 Transvaginal  ultrasound examination
  of the pelvis and measurement of
  serum beta-hCG concentration are
  then performed weekly until the level
  is undetectable.
 Alternatively, prophylactic treatment
  with one dose of methotrexate can be
  given after all salpingostomies.
        Gracia, etal. Fertil Steril 2001.
  Ectopic implantation usually occurs
  because clinical or subclinical salpingitis
  has caused anatomic and functional
  changes in the fallopian tubes.
 These changes are typically bilateral
  and permanent.
 it is not surprising that ectopic
  pregnancy often leads to recurrent
  ectopic pregnancy and infertility.
  In women with a history of ectopic
  pregnancy, 38 to 89 percent will
  achieve a subsequent intrauterine
  gestation .
 Recurrent ectopic pregnancy is 15
  percent (range 4 to 28 percent).
              Farquhar, Lancet 2005.
 The recurrence risk rises to 30
  percent following two ectopic
  pregnancies.
          Tulandi,etal.Fertil Steril 1988.
Recurrence   of an ectopic
pregnancy seems to be
similar for all modes of
treatment and is variously
quoted as up to 26%, with
averages around 6-12%.
akram103g@yahoo.com
Pleasesend your
 comment.
0020125665991

								
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