Volume 1 Issue 2, February 2014

Gupta AS

Retrospective Diagnosis of Advanced Carcinoma Endometrium from Hepatic Nodule
Panchbudhe S, More V, Mali K, Satia MN.

Cesarean Scar Ectopic Pregnancy
Khadkikar R, Wakchaure G, Prasad M, Chauhan AR.

Heterotopic Pregnancy After IVF-ET
More V, Panchbudhe S, Mali K, Satia MN.

Robert’s Uterus
Channawar S, Chamariya S, Chauhan AR, Mayadeo NM.

Pregnancy in a case of Constrictive pericarditis
Chakre S, Pardeshi S, Warke HS, Mayadeo NM.

Simultaneous Scar and Tubal Twin Ectopic Gestation
Jamdade K, Gupta AS.

Conservative Management of Corpus Luteum Hematoma
Pandey N, Gupta AS.

Hemoperitoneum In Coagulopathy: Conservative Treatment
Ansari MF, Parulekar SV.

Myomectomy: Lateral Extraperitoneal Approach
Parulekar SV

Dr. A.S.Gupta
Ectopic pregnancy is a major concern in reproductive age women. About 1 to 2 % of pregnancies are located in the extra uterine sites. It can disrupt the fertility potential of a young woman. Advances in assisted reproductive technologies (ART), super ovulation, better antimicrobial therapy of pelvic inflammatory disorders, conservative treatment modalities for ectopic gestations and increasing rate of cesarean deliveries have not only increased the incidence of ectopic gestations but pregnancy has found new sites to  implant. Further, twining in ectopic gestations has also increased. Simultaneous presence of two or more pregnancies in different sites is known as heterotopic pregnancy. Usually one pregnancy is intrauterine and the other is extrauterine situated frequently in the fallopian tube. Incidence of heterotopic gestations has increased from 1 in 30,000 to 1 in 3900 after the use of ART for conception. An incidence of 1.5 heterotopic pregnancies for every 1000 ART pregnancies has been reported in the United States during the period between 1999 and 2002. Pregnancies conceived with ART show an incidence of 11.7% of heterotopic pregnancy and reduction of tubal ectopic to 82.2% from  over 90% in spontaneous conceptions. This incidence is probably higher due to greater incidence of tubal disease, higher estrogen levels, and greater viscosity of the transfer medium and the method of embryo transfer. Heterotopic pregnancies pose diagnostic challenges as after detection of one pregnancy (usually an intrauterine one) an additional pregnancy is not considered as the symptoms and signs of early pregnancy, threatened abortion, like amenorrhea, pain in abdomen, nausea, vomiting and vaginal bleeding overlap. Significant abdominal pain with an intrauterine gestation should alert the clinician to the possibility of a simultaneous ectopic gestation. β HCG levels in a heterotopic pregnancy usually reflect the intrauterine rather than the ectopic gestation. The ectopic pregnancy usually gets diagnosed only after a catastrophic event like a hemoperitoneum occurs. Such eventualities can be averted provided all clinicians are alert and vigilant and they think ‘ectopic’ in every woman who presents with an early pregnancy. Exploratory laparotomy is needed if hemoperitoneum is suspected. However, laparoscopy aids in the diagnosis in a stable patient. Treatment needs to be personalized to the ectopic site. Live intrauterine pregnancy and a coexisting unruptured ectopic gestation cannot be managed conservatively by systemic methotrexate. Conservative laparoscopic surgery or ultrasonic local injection of potassium chloride in the gestational sac can be alternative treatment modalities in a stable patient.
Cesarean Scar Ectopic Gestation: With the increasing cesarean births complications in the subsequent pregnancies like morbid adhesions of placenta, placenta previa and scar pregnancies are on the rise. These are type of intramural or an intramyometrial pregnancy. The pregnancy implants on the previous cesarean or hysterotomy scar and is surrounded all round by the myometrium and is overtly unconnected with the endometrial cavity. Some of these pregnancies are partially in the uterine cavity and grow till term. Pregnancies that have completely invaded the myometrium tend to rupture in the 1st trimester. Microscopic or wedge defects in the scar allow the pregnancy to burrow in the myometrium and implant there. Besides cesarean and hysterotomy scars, false tracts due to intrauterine device and previous dilatation and curettage, in vitro fertilization and adenomyosis are some other risk factors for scar pregnancies. Various ultrasonographic diagnostic features like bulging of the cesarean scar especially in close proximity of the bladder, bulge or distortion of the anterior outline of the uterus, and a gestation sac with a live embryo have been reported. Doppler signals may further aid in the diagnosis. Close differential diagnosis will be a cervical pregnancy and morbid adhesion of the placenta. Surgical excision of the pregnancy and the scar with repair is the preferred treatment modality even in stable patients as it not only allows the resection of the pregnancy but also allows the clinician to excise and repair the scar. Conservative treatments like systemic methotrexate, local ultrasonographic administration of injection of potassium chloride in the sac are the treatment options for an unruptured scar pregnancy. However, these patients need prolonged follow up as the resolution of the pregnancy is very slow and the chance of uterine rupture and hemorrhagic shock remain. Hysterectomy and uterine artery embolization have also been used in select patients. In subsequent pregnancies these patients are at an increased risk for re-implantation at the scar, placenta accreta, scar rupture and severe hemorrhage. An early ultrasound in the next pregnancy is recommended to see for the site of implantation.
A patient with a heterotopic gestation presented in this issue had one of the rarer types of twin ectopic gestations. Both the pregnancies were extra uterine in location. This patient was extremely fortunate. The preoperative diagnosis of ruptured tubal ectopic and a normal intrauterine pregnancy was proven wrong intraoperatively. An unruptured tubal ectopic and a ruptured scar ectopic was seen on exploratory laparotomy. Had it been the other way round tubal rupture would have been treated and the scar ectopic would have been missed. It would then have subsequently presented with a catastrophe and probably a delayed diagnosis and its consequences. In another case, the patient had an intrauterine and a cervical ectopic pregnancy. In the near future the scientific community is likely to encounter more of such cases. Awareness and the various modes of presentation are aids to an early diagnosis of this condition. Treatment should be determined by the site of implantation and the condition of the patient.
It gives me great pleasure to present this second issue of the journal to the readers and hope the cases in this will give insight into various aspects in clinical practice.