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Objective: To report a heterotopic pregnancy with successful delivery of monochorionic-diamniotic twins after rupture of the tubal ectopic gestation., Design: Case report. University teaching hospital., Patient(s): A patient with heterotopic twin monochorionic-diamniotic pregnancy., Intervention(s): Surgical removal of the ectopic pregnancy., Main Outcome Measure(s): Pregnancy course and outcome. The patient successfully delivered twins., Conclusion(s): Heterotopic pregnancy after clomiphene citrate administration may have a complicated course, but could end in successful live birth of twins.

Objective: To compare two strategies for managing women after linear salpingostomy for treatment of tubal pregnancy: observation and prophylactic methotrexate., Design: Decision analysis., Setting: Outpatient tertiary-care center., Patient(s): One thousand hypothetical women treated with a linear salpingostomy for ectopic pregnancy., Intervention(s): Observation after salpingostomy and treatment of persistent ectopic pregnancy with a single dose of methotrexate (current standard of care) versus treatment with prophylactic methotrexate at the time of salpingostomy., Main Outcome Measure(s): Number of ruptured ectopic pregnancies, surgical procedures, complications, and cost for each group (observation vs. prophylaxis)., Result(s): Prophylactic methotrexate results in fewer cases of tubal rupture (0.4% vs. 3.7%) and fewer procedures (1.9% vs. 4.7%) at a lower cost ($67.55 less/patient) compared with observation alone. Methotrexate-associated complications occur more frequently with prophylaxis (5.5% vs. 0.8%). Certain conditions change which strategy is preferable. Observation is the best strategy when the persistent ectopic pregnancy rate is <9%, the success of prophylaxis is <95%, the complication rate associated with methotrexate is >18%, or the rupture rate of persistent ectopic pregnancies is <7.3%., Conclusion(s): Prophylactic methotrexate at the time of linear salpingostomy for the treatment of ectopic pregnancy is preferable to observation as long as certain conditions exist.

Objective: To evaluate the ability of noninvasive diagnostic tools to predict tubal rupture and active bleeding in patients with tubal pregnancy., Design: Prospective cohort study., Setting: Two large teaching hospitals in Amsterdam, The Netherlands., Patient(s): Consecutively seen patients with suspected tubal pregnancy who were scheduled to undergo confirmative laparoscopy., Main Outcome Measure(s): Tubal rupture and/or active bleeding confirmed at laparoscopy., Result(s): Sixty-five (23%) of 288 patients had tubal rupture and/or active bleeding at laparoscopy. Abdominal pain, rebound tenderness on abdominal examination, fluid in the pouch of Douglas at transvaginal ultrasound examination, and a low serum hemoglobin level were independent predictors of tubal rupture and/or active bleeding. Pregnancy achieved with the use of IVF-ET and the presence of an ectopic gestational sac or an ectopic mass at ultrasound examination reduced the risk of tubal rupture. Abdominal pain was the most sensitive predictor, with a sensitivity of 95%., Conclusion(s): Because the nonsurgical management of tubal pregnancy should be used only when the risk of tubal rupture and/or active bleeding is low, it can be safely applied in only a limited number of patients.

Salpingitis isthmica nodosa has been studied in relation to female infertility and tubal ectopic pregnancy. The incidence of this lesion in a control Caucasian population was 0.6%, as compared with incidences of 2.86% in an ectopic group and 50% in a small infertility group undergoing tuboplasty. It is suggested that salpingitis isthmica nodosa should be considered as an etiologic factor in these reproductive disorders. Chronic tubal spasm is suggested as the underlying process.

Consideration of reproductive potential following multiple ectopic pregnancies is important in counseling patients and when choosing a conservative surgical approach (salpingotomy, salpingostomy), partial salpingectomy, or in vitro fertilization. The cases of 336 patients at Yale-New Haven Hospital who had ectopic pregnancies between 1976 and 1981 were evaluated. Thirty-two patients (9.5%) had two ectopic pregnancies. Twenty-three patients (71.8%) were followed. Six of these (26.1%) were not able to conceive because of surgical sterilization, and four (17.4%) were not trying to conceive. Of those 13 patients (56.5%) actively trying to conceive and having at least one tube remaining, 4 (30.8%) had term intrauterine gestations. One had a third ectopic gestation, which represented 20% of all conceptions, or 7.7% of those individuals trying to conceive. Our results indicate that although the reproductive potential after two ectopic pregnancies is poor, viable pregnancies do occur, and the repeat ectopic pregnancy rate is not high enough to preclude a repeat conservative surgical approach.