Introduction. Interstitial pregnancy (IP) is an ectopic pregnancy (EP) located in the portion of the fallopian tube that penetrates the uterine muscular layer. Incidence increased in the last two decades with the widespread use of the assisted reproductive techniques. It is estimated in 1-6% of all the EPs, with a maternal mortality rate of 2.0-2.5%. Clinical presentation, gestational age at diagnosis, beta-human chorionic gonadotropin (β-hCG) levels, ultrasound features, and patient preference, should be considered to determine the best management: surgical, medical treatment, or close observation. We report two cases of IP successfully managed with systemic MTX and Mifepristone: in one case β-hCG was >10.000 mIU/mL and a vital embryo was present. Materials and Methods. A literature search was carried out on MEDLINE, EMBASE, and PUBMED. We identified two cases of IP referred to the Institute for Maternal and Child Burlo Garofolo, Trieste. Data related to clinical presentation, β-hCG, and ultrasound scan at the moment of the diagnosis were recorded. In one of the cases, the β-hCG level was >10.000 mIU/mL, and a vital embryo was testified at an ultrasound scan. The patient was asymptomatic and she was treated using multidose systemic Methotrexate (MTX) combined with Mifepristone. In the second case, in the presence of a clinically stable patient with β−hCG>10.000 mIU/mL, it was chosen that the administration of Mifepristone combined with a double dose of MTX. β-hCG levels and ultrasound examinations were performed weekly until a complete resolution of the IP. Results. In the first case, β-hCG dropped down in 5 days and became undetachable in 30 days. In the second case, β-hCG became undetectable in 47 days. The first-line therapy in asymptomatic women could be addressed to a combined protocol, consisting of a systemic multidose MTX regimen with a single oral dose of Mifepristone. Conclusions. Clinical management of IP remains a debated topic. In selected cases, a systemic multidose MTX regimen combined with a single oral dose of Mifepristone could be considered also in the presence of high serum β-hCG.
Background and objectives: Cervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) in which the embryo implants and grows inside the endocervical canal. Early diagnosis is essential in order to allow conservative medical and surgical treatments. Although many treatment approaches are disponible, the most effective is still unclear. The aim of this study is to evaluate the efficacy of hysteroscopic management in early CP in order to preserve future fertility. Materials and Methods: This is a retrospective observational case series. Five patients with a diagnosis of CP, hemodynamically stables and managed conservatively between 2014 and 2019 at the Institute of Child and Maternal Health Burlo Garofolo in Trieste, Italy, were included. Four patients, with βhCG levels > 5000 mUi/mL were managed by hysteroscopy, with or without a previous systemic Methotrexate (MTX). One case with βhCG levels < 5000 mUi/mL was treated using MTX combined to Mifepristone and Misoprostol. Results: In one patient treated by hysteroscopy alone it occurred a profuse vaginal bleeding with necessity for blood transfusion. Haemorrhage was controlled by a second hysteroscopic procedure. No complications, such as vaginal bleeding, were recorded in the other cases. Serum β-hCG levels become undetectable in a range of 15–40 days after hysteroscopic management; after medical treatment it become undetectable after 35 days. Serum βhCG levels had a faster drop the day after hysteroscopy than post medical management. The onset of a spontaneous pregnancy at the normal implantation site occurred after five months in one case treated by hysteroscopy. Conclusions: Many therapeutic approaches are effective for CP treatment. Hysteroscopy, alone or in combination with MTX, may provide a greater effect on the descent of βhCG, leading to a reduction of the hospitalization stay, decreasing costs and period for attempt pregnancy. Further prospective studies on larger samples are needed to define therapeutic protocols for CP management.
Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.
Non-tubal ectopic pregnancies (NT-EPs) are rare but potentially life-threatening conditions. The incidence ranges are between 5–8.3% of all ectopic pregnancies. For this retrospective observational study, 16 patients with NT-EP and treated from January 2014 to May 2020 were recruited. Demographic details, symptoms, Beta human chorionic gonadotrophin (β-hCG) levels, ultrasound findings, management and treatment outcomes were presented. In hemodynamically stable patients, diagnosis was made using ultrasounds and β-hCG levels. Laparoscopy was essential to identify and remove the ectopic pregnancy in clinical unstable patients. A radical laparoscopic approach was chosen in one case of cervical pregnancy diagnosed late in the first trimester. Medical treatment and minimally invasive procedure, alone or combined, resulted in effective strategies in asymptomatic women with an early diagnosis of NT-EP. We report cases of cervical pregnancies successfully treated by hysteroscopy alone or combined with medical treatment, the first case of scar pregnancy treated by mini-reseptoscope and curettage and the fifth case of interstitial pregnancy treated with Methotrexate and Mifepristone. In this manuscript we report a single center experience in the management of NT-EPs with the aim of outlining the importance of the early diagnosis for a minimally invasive treatment in order to reduce maternal morbidity and mortality and preserve future fertility.
Objective: To identify the possible causes of spontaneous bladder rupture after normal vaginal delivery and to propose a diagnostic and therapeutic algorithm. Material and Methods: MEDLINE (PubMed), Web of Science and Scopus databases were searched up to August 2020. Manuscripts considered were published from 1990 and only English articles were included. The research strategy adopted included the following terms: (bladder rupture) AND (spontaneous) AND (delivery). 103 studies were identified. Duplicates were found through an independent manual screening. Subsequently, two authors independently screened the full text of articles and excluded those not pertinent to the topic. Discrepancies were resolved by consensus. Finally, thirteen studies were included. Results: PRISMA guidelines were followed. For each study, fetal weight, catheterization during labor, parity, maternal age, occurrence time, previous abdominal or pelvic surgery, symptoms complained of, diagnostic methods, and treatment were considered. Median age was 26.0 (range 20–34 years); median presentation time was 3.0 days after delivery (range 1–20 days); and median newborn weight was 3227.0 g (range 2685–3600 g). Catheterization during labor was reported only in four of the thirteen cases (30.8%) identified. The symptoms most frequently complained of were abdominal pain and distension, fever, oliguria, haematuria and vomiting. Instrumental diagnosis was performed using X-rays in five cases and computerized tomography in six cases. Ultrasound was chosen in five cases as a first diagnostic tool. In two cases, cystography was performed. Treatment was always laparotomic repair of the visceral defect. Conclusion: Abdominal pain, increased creatinine and other signs of kidney failure on blood tests should lead to suspicion of this complication. Cystourethrography is regarded as a procedure of choice, but a first ultrasound approach is recommended. The main factor for the therapeutic choice is the intraperitoneal or extraperitoneal rupture of the bladder. Classical management for intraperitoneal rupture of the bladder is surgical repair and urinary rest.
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