Ectopic Pregnancy Togas Tulandi Editor Ectopic Pregnancy A Clinical Casebook Editor Togas Tulandi Department of Obstetrics and Gynecology McGill University Montreal Québec Canada ISBN 978-3-319-11139-1    ISBN 978-3-319-11140-7 (eBook) DOI 10.1007/978-3-319-11140-7 Library of Congress Control Number: 2014959416 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2015 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Springer International Publishing is part of Springer Science+Business Media (www.springer.com) Preface There have been many reviews and books on ectopic pregnancy So, why produce another book? In fact, a casebook on ectopic pregnancy is unique and has never been published More importantly, due to advances in the management of ectopic pregnancy, clinicians, and researchers are not always current with their knowledge In this book, we presented real cases that were treated by our expert contributors Each chapter contains a case report, a discussion about diagnosis and assessment, and management of the case followed by images At the end of the chapter, we provide clinical pearls and pitfalls about the topic The book starts with risk factors related to ectopic pregnancy, and human chorionic gonadotropin (hCG) discriminatory zone It is followed by “Pregnancy of unknown location” and “Ectopic pregnancy after in-vitro fertilization.” Chapters 5–7 deal with medical and surgical treatments of ectopic pregnancy For medical treatment, patient compliance is crucial and discussed in Chap. 8 Inadvertent methotrexate administration to a woman with an intrauterine pregnancy and its implication is discussed in Chaps. 9 and 10 Different types of ectopic pregnancy including the rare types and their management are discussed in Chaps. 10–20 The last chapter discusses fertility after an ectopic pregnancy This concise casebook on ectopic pregnancy is for practicing physicians, obstetricians and gynecologists, residents and fellows v vi Preface in Obstetrics and Gynecology, and allied health care professionals Readers will gain an understanding of many aspects of different types of ectopic pregnancy and their management We also hope that this book will be helpful in preparing students for examination, and directing new investigations and the clinical management of patients Professor of Obstetrics and Gynecology, and Milton Leong Chair in Reproductive Medicine McGill University Editor Togas Tulandi MD, MHCM Contents 1  Identification of Risk Factors of Ectopic Pregnancy������  1 Ali Ardehali, Ishwari Casikar and George Condous 2 Discriminatory Serum hCG Level for Ectopic Pregnancy���������������������������������������������������������������������������  11 Ishai Levin and Shiri Shinar 3  Pregnancy of Unknown Location�������������������������������������  19 Shabnam Bobdiwala and Tom Bourne 4  Ectopic Pregnancy After In Vitro Fertilization���������������  27 Lisa Caronia, Rebecca Flyckt and Tommaso Falcone 5  Surgical Treatment of Ectopic Pregnancy�����������������������  33 Jillian Main and Camran Nezhat 6  Bleeding Ectopic Pregnancy����������������������������������������������  41 M Jean Uy-Kroh 7  Medical Treatment of Ectopic Pregnancy������������������������  49 Togas Tulandi 8 Compliance with Methotrexate Treatment for Ectopic Pregnancy�������������������������������������������������������  55 Ishai Levin and Benny Almog vii viii Contents 9  Inadvertent Methotrexate Administration��������������������  61 Togas Tulandi and Senem Ates 10 Effect of Methotrexate Treatment for Ectopic Pregnancy on Current and Subsequent Pregnancy������  69 Shirin Namouz-Haddad and Gideon Koren 11  Interstitial Pregnancy������������������������������������������������������  77 Margaret Dziadosz, Ana Monteagudo and Ilan E Timor-Tritsch 12  Cervical Pregnancy����������������������������������������������������������  85 Abdulrahman Alserri and Togas Tulandi 13  Ovarian Ectopic Pregnancy��������������������������������������������  93 Warren J Huber and Gary N Frishman 14  Cesarean Scar Pregnancy������������������������������������������������   101 Marcos Cordoba, Ana Monteagudo and Ilan E Timor-Tritsch 15  Abdominal Pregnancy�����������������������������������������������������  109 Amanda Ecker MD and Richard Guido MD 16  Intramural Pregnancy�����������������������������������������������������  115 Maria Memtsa and Davor Jurkovic 17  Heterotopic Pregnancy����������������������������������������������������  123 Mallory Stuparich and Kimberly A Kho 18  Retroperitoneal Ectopic Pregnancy�������������������������������  131 Ana Monzo-Miralles, Alicia Martinez-Varea and Antonio Pellicer 19  Ectopic Molar Pregnancy������������������������������������������������  139 Atif Zeadna and Togas Tulandi Contents ix 20  Rudimentary Uterine Horn Pregnancy�������������������������  145 Mette Petri Lauritsen and Marianne Johansen 21  Fertility After Tubal Ectopic Pregnancy������������������������  153 Perrine Capmas, Jean Bouyer and Hervé Fernandez Index����������������������������������������������������������������������������������������  163 ix Contributors Benny Almog MD Lis Maternity Hospital, Tel Aviv Sourasky Medical Center Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Abdulrahman Alserri MD McGill University Health Center, Montreal, QC, Canada Ali Ardehali MD Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, Nepean Hospital, University of Sydney, Penrith, Sydney, Australia Senem Ates MD  McGill University Health Center, Montreal, QC, Canada Shabnam Bobdiwala MD  Queen Charlotte and Chelsea Hospital, Imperial College London, London, UK Tom Bourne MD, PhD  Queen Charlotte and Chelsea Hospital, Imperial College London, London, UK Jean Bouyer MD Centre of research in Epidemiology and population health (CESP), Inserm, Le Kremlin Bicêtre, France Perrine Capmas MD  Service de Gynécologie Obstétrique, Hôpital Bicêtre, GHU Sud, AP-HP, Le Kremlin Bicêtre Cedex, France Centre of research in Epidemiology and population health (CESP), Inserm, Le Kremlin Bicêtre, France Univ Paris Sud, Le Kremlin Bicêtre, France xi 150 M P Lauritsen and M Johansen diate operative intervention If a rudimentary uterine horn is identified before conception, elective surgical removal by laparoscopy is recommended [3] Outcome An emergency laparotomy was performed revealing a massive hemoperitoneum On the left side of the uterus, a ruptured rudimentary horn containing the placenta was found The fetus was found floating in the abdominal cavity According to its crown– heel length, it was estimated to be 16 weeks of gestational age There were no visible malformations An excision of the rudimentary uterine horn along with the placenta and a left salpingectomy were performed Estimated blood loss was 4.8 l and blood transfusions and fresh-frozen plasma were given The woman recovered without complications and was discharged days later Clinical Pitfalls When a pregnant woman presents with abdominal pain and hemorrhagic shock, a ruptured uterine horn pregnancy should be considered This is despite the history of previous normal pregnancies • Pay special attention to women who have not attended any antenatal care • Rudimentary horn pregnancies can usually be differentiated from a tubal ectopic pregnancy by the more advanced gestation at the time of clinical presentation • When managing a ruptured rudimentary uterine horn pregnancy, massive hemorrhage due to abnormal implantation of the placenta should be expected • A history of recurrent pregnancy loss, abnormal fetal presentation, or preterm delivery should alert the physician to the possibility of uterine anomalies 20  Rudimentary Uterine Horn Pregnancy 151 • Renal agenesis, urinary retention, or recurrent pyelonephritis may indicate a uterine anomaly • The presence of uterine anomalies should be carefully assessed when performing a cesarian section References Buttram V, Gibbons W Mullerian anomalies: a proposed classification (an analysis of 144 cases) Fertil Steril 1979;32:40–6 Contreras KR, Rothenberg JM, Kominiarek MA, Raff GJ Hand-assisted laparoscopic management of a midtrimester rudimentary horn pregnancy with placenta increta: a case report and literature review J Minim Invasive Gynecol 2008;15:644–8 Dicker D, Nitke S, Shoenfeld A, Fish B, Meizner I, Ben-Raphael Z Laparoscopic management of rudimentary horn pregnancy Hum Reprod 1998;13:2643–4 Grimbizis FG, Gordts S, Di Spezio Sardo A, Brucker S, De Angelis C, Gertolet M, et al The ESHRE–ESGE consensus on the classification of female genital tract congenital anomalies Gynecol Surg 2013;10:199– 212 Heinonen PK, Saarikoski S, Pytsynen P Reproductive performance of women with uterine anomalies Acta Obstet Gynecol Scand 1982;6:157– 62 Jayasinghe Y, Rane A, Stalewski H, Grover S The presentation and early diagnosis of the rudimentary uterine horn Obstet Gynecol 2005;105:1456–67 Nahum GG Rudimentary uterine horn pregnancy: the 20th-century worldwide experience of 588 cases J Reprod Med 2002;47:151–63 Patra S, Puri M, Trivedi SS, Yadav R, Bali J Unruptured term pregnancy with a live fetus with placenta percreta in a non-communicating rudimentary horn Congenit Anom (Kyoto) 2007;47:156–7 Reichman D, Laufer MR, Robinson BK Pregnancy outcomes in unicorneate uteri: a review Fertil Steril 2009;91:1886–94 10 The American Fertility Society American Fertility Society classification of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions Fertil Steril 1988;49:944–55 Chapter 21 Fertility After Tubal Ectopic Pregnancy Perrine Capmas, Jean Bouyer and Hervé Fernandez Case Study The patient was a 35-year-old woman who presented at weeks’ gestation with abdominal pain and vaginal bleeding Her past story revealed severe preeclampsia and cesarean delivery at 34 weeks’ gestation Ultrasound examination showed a left tubal ectopic pregnancy (15 mm hematosalpinx) without hemoperitoneum The serum human chorionic gonadotropin (hCG) level was 1500 IU/l She was then treated with a single dose of methotrexate intramuscularly P. Capmas () · H. Fernandez Service de Gynécologie Obstétrique, Hôpital Bicêtre, GHU Sud, AP-HP, 78, avenue du Général Leclerc, 94276 Le Kremlin Bicêtre Cedex, France e-mail: perrine.capmas@bct.aphp.fr Univ Paris Sud, 94276 Le Kremlin Bicêtre, France J. Bouyer · P Capmas · H Fernandez Centre of research in Epidemiology and population health (CESP), Inserm, U1018, 94276 Le Kremlin Bicêtre, France e-mail: jean.bouyer@inserm.fr H. Fernandez BICETRE, 78 rue du General Leclerk, 94270 Le Kremlin Bicetre, France e-mail: herve.fernandez@bct.aphp.fr © Springer International Publishing Switzerland 2015 T Tulandi (ed.), Ectopic Pregnancy, DOI 10.1007/978-3-319-11140-7_21 153 154 P Capmas et al (1 mg/kg body weight) The hCG levels were 1980 IU/L on day of injection, 1458 IU/L on day 7, 2 IU/L on day 28 My Management a Agree with the above management b I prefer an expectant management c For fertility reason, surgical management is a better treatment Diagnosis and Assessment Ectopic tubal pregnancy is still a leading cause of maternal mortality in the first trimester of pregnancy Early diagnosis and treatment has allowed medical management and minimally invasive treatment with fertility preservation There are two groups of patients with ectopic tubal pregnancy The first group consists of women who can be managed by medical treatment or conservative surgery (salpingostomy), and the second group needs to be treated surgically (conservative or radical) Ectopic tubal pregnancy is also often associated with a difficulty to conceive There are data on spontaneous subsequent fertility after ectopic pregnancy but very few about fertility after assisted reproduction treatment (ART) There are also few published data on the indications of ART after a previous ectopic pregnancy [1] Management This group of patients can be treated medically or with conservative surgery by salpingostomy Many criteria have been used to define this group These include the initial serum hCG level, progesterone level, tubal diameter, and hemoperitoneum [2–8] Some composite scores have also been used [9, 10] The most commonly 21  Fertility After Tubal Ectopic Pregnancy 155 used criterion is the initial hCG level [11], but there has been no agreement on the cutoff level [3, 5, 6, 8] Published data on fertility after ectopic pregnancy are mainly observational However, prospective studies from ectopic pregnancy registries in two regions of France (Auvergne and Nord) have concluded that fertility is similar after medical treatment and conservative surgery, but lower after radical surgery [12–15] In the Auvergne registry, 1064 women were included between 1992 and 2008 The rate of subsequent fertility years after conservative surgery as well as after medical treatment was similar (76 %) However, the number of women with a medical treatment (119 women) was low and those with a conservative surgery (646 women) included in the registry consisted of patients who could be treated with medical, conservative, or radical surgery [12] Three randomized trials comparing medical treatment (intramuscular or local injections of methotrexate) and conservative surgery found different results about subsequent fertility, but they probably lacked the power to reach a definitive conclusion [16– 18] The studies were designed to compare efficacy of treatment with low statistical power Dias Pereira et al evaluated fertility after treatment of ectopic pregnancy in 74 women Spontaneous intrauterine pregnancy occurred in 36 % of cases after medical treatment and in 43 % after conservative surgery ( p: nonsignificant, relative risk (RR): 0.89 (0.42– 1.9)) [16] In another study of 34 women, Zilber et al found that subsequent intrauterine pregnancy rates after conservative surgery (83.5 %) and after local methotrexate treatment (81 %) were comparable [17] On the other hand, Fernandez et al reported that the rate of intrauterine pregnancy was 96.3 % after local methotrexate treatment ( n: 27) and 62 % after conservative surgery (n: 29; p