Poster presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S531–S867
W005 OVARIAN ECTOPIC PREGNANCY, A DIAGNOSTIC CHALLENGE? A CASE REPORT A. Slater1 , D. Siassakos1 . 1 Obstetrics and Gynaecology, North Bristol NHS trust, Bristol, United Kingdom Objectives: Ovarian ectopic pregnancies are a rare occurrence and comprise just 0.5% of all ectopics. Diagnosing ovarian ectopic pregnancies can be a challenge often due to the mild presenting symptoms and unremarkable examination ﬁndings. This case report of a 26 year old woman illustrates the importance of a high index of suspicion and the need for early transvaginal scanning for the accurate diagnosis of ovarian ectopic pregnancies. Materials: A 26 year old primip presented at 7 weeks gestation with 2 episodes of painless vaginal bleeding. She was systemically well with no other symptoms. Her physical examination was unremarkable with a soft non-tender abdomen, a mobile uterus with no adnexal masses or tenderness and no cervical excitation. A TVUSS revealed a thin endometrium and clearly showed an extrauterine pregnancy with a fetal pole equating to 7 weeks gestation in the right adnexa. Serum bhCG 1428 and progesterone <5. Methods: Although clearly extrauterine at the time of scanning, it was unclear whether the ectopic was ovarian or tubal in origin. The literature suggests that there are no set criteria for the diagnosis of ovarian ectopic pregnancies, but individual case reports often comment on the presence of a cystic structure surrounded by healthy ovarian tissue. Table: Ultrasound features in ectopic pregnancy Tubal
Extraovarian adnexal mass Tubal Ring sign (hyperechoic ring around gestation sac) Trilaminar pattern Pseudogestational sac Free ﬂuid
Yolk sac and embryo less commonly seen
cyst with wide echogenic ring
Figure: Transvaginal ultrasound image showing 7 week sized extrauterine pregnancy in right adnexa. Results: The patient was consented for a diagnostic laparoscopy +/− proceed which conﬁrmed a left sided ovarian ectopic pregnancy. A partial oopherectomy was performed to remove the ectopic, conserving more than 2/3rd of the ovary. Histology conﬁrmed the presence of ovarian tissue with a gestational sac containing chorionic villi and trophoblastic tissue. Conclusions: Ectopic pregnancies are an important cause of mortality accounting for 10% of all direct maternal deaths in the ﬁrst trimester. The often mild presenting symptoms and unremarkable examination ﬁndings mandate that a high index of suspicion is required to diagnose ectopic pregnancy. In this case, the appearance
of an extrauterine pregnancy at scan was clear, however such obvious diagnoses are unusual. Differentiating tubal from ovarian ectopics can be difﬁcult, and no speciﬁc ultrasound criteria exist to distinguish one from the other with 100% accuracy. A take home message for juniors and seniors alike, is the importance of counselling women about the possibility of partial or complete oopherectomy when considering a therapeutic laparoscopy for management of ectopic pregnancy, and including it on all consent forms where location of the ectopic is not certain. W006 A SUCCESSFUL TREATMENT OF A CAESAREAN SCAR PREGNANCY (CSP) WITH MIFEPRISTONE AND MISOPROSTOL AND LITERATURE REVIEW N.A. Pope1 . 1 Queen’s Hospital, Burton-Upon-Trent, United Kingdom Objectives: To compare the success of treatment of a CSP with mifepristone and misoprostol with other methods in the literature. Materials: Case notes. Methods: A retrospective case study and a review of the literature using MEDLINE/PubMed database. The words ’caesarean scar ectopic pregnancy’ were used in addition to reviewing secondary references of the publications obtained in order to identify additional articles and case reports. Results: A 32 year old P1, with a body mass index of 45, presented 18 months post caesarean section (CS) at approximately 5 weeks amenorrhoea with painless pv spotting. Transvaginal ultrasound scan (TVS) showed an irregular gestational sac (gs) of 6 weeks 3 days with a yolk sac in the lower uterine cavity. Another painless pv bleed 2 weeks later and a further TVS showed a single live fetus CRL 19.4 mm (8weeks 3days gestation) located in the previous CS scar. She was keen to retain her fertility and opted for medical management. She was given Mifepristone 200 micrograms orally followed by Misoprostol 800 micrograms pv. She recieved a further Misoprostol 200 micrograms pv 3 hourly by two doses according to our hospital protocol. A TVS done the following day showed the gs was now in the uterine cavity with an absent fetal heart. She was managed conservatively, but as no products of conception were passed she was taken to theatre for an evacuation of retained products using a blunt curette 6 days post Misoprostol. The procedure was uneventful. Her post op course was complicated by intermittent pv bleeding managed conservatively. Her bleeding stopped and a TVS 3 months later conﬁrmed an empty uterus. Conclusions: Caesarean scar pregnancy is deﬁned as an ectopic pregnancy embedded in the myometrium of a previous CS scar. It maybe linked to the development of a microscpic tract between the myometrium and the endometrial canal. It can result in uterine rupture, haemorrhage, hysterectomy with loss of fertility and increased maternal morbidity. Early diagnosis by TVS is paramount in the management and, due to its rarity there are no universal guidelines. Treatments include expectant, local and systemic methotrexate, suction curettage, laparoscpoic resection and repair, total abdominal hysterectomy. In our case as the patient wanted to preserve her fertility and opted for medical management with Mifepristone and Misoprostol. This suceeded in terminating the conceptus but neccisitated a D&C to empty the uterus. This offers another management option in an area fraught with management dilemmas. W007 THE CHALLENGE OF CERVICAL PREGNANCY L. Gutierrez Perez1 , C.E. Ferreira Novaes1 , C. Moreira Cooper1 , C.A.A. Barboza Montenegro1 , J. de Rezende Filho1 . 1 Santa Casa da Misericordia, Rio de Janeiro, Brazil Objectives: The objective of this case report is to evaluated the challenge of this particular pregnancy complication, how difﬁcult can be to make a decision and the sub sequent resolution with the use of methotrexate.