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Partial or complete hydatidiform mole (HM) affects approximately 1 in 500 to 1,000 pregnancies. Previous small series suggest that histopathologic diagnosis of HM may be difficult in tubal ectopic pregnancies. The histopathology database of a regional Trophoblastic Disease Unit was searched to identify cases with a referral diagnosis of tubal HM, and the histopathologic findings were reviewed. During the study period (1986-2004 inclusive), there were 132 cases. After central review by specialist histopathologists, the final diagnosis was ectopic partial mole in two, ectopic complete mole in five, and ectopic hydatidiform mole (not otherwise specified) in one. The final diagnosis of definite hydatidiform mole was made in eight (6%) cases, significantly less than in referred uterine curettage specimens, in which approximately 90% have a confirmatory diagnosis of HM (Z = 12.9; p < 0.0001). No cases in this series developed persistent gestational trophoblastic disease, the human chorionic gonadotropin concentration spontaneously returning to normal. Ectopic pregnancies, where managed surgically, should be submitted for histopathologic examination; however, the pathologist should be aware that the degree of extravillus trophoblastic proliferation may appear more florid compared with evacuated uterine products of conception. Molar pregnancy should only be diagnosed when strict criteria regarding morphologic abnormalities previously described in uterine evacuation material are applied.

Objective: To evaluate leucocytic infiltration of fetomaternal interface in ectopic pregnancy and to evaluate the changes in cell immunity against trophoblast (AT-CMI) in women with extrauterine pregnancy (GEU) in their medical history. To assess the effect of these factors on possible fertility disorders in a woman., Design: A retrospective study., Setting: Mother and Child Care Institute, Prague., Methods: In most of the patients, we addressed GEU through laparoscopy. The tube was extirpated in toto and immediately fixed in Baker's solution. Thereafter, it was prepared in a dissection microscope and then processed in a standard way. In order to identify the intensity of AT-CMI, we used the leucocyte migration inhibition test. The cytotrophoblastic cell line JAR was used as an antigen. The degree of inhibition of the migration was monitored by means of a computer image analyser. Inhibition of migration below 75% was rated as favourable., Results: We monitored the presence of inflammatory infiltrate in the place of implantation and correlated the findings with the hCG levels and the presence of the foetal ovum or its part in the tube. In 28 patients (23.5%) of the total number of 119 patients in the group, we observed an inflammatory infiltrate in the place of implantation. In these patients, the hCG levels were lower and in 17 of them (60.7%) we did not prove the presence of a foetal ovum or its parts. In women with GEU in their medical history, the AT-CMI positivity was established in 61.1% of the women 1 year after surgery, in 56.8% of the women 1-3 years after surgery and in 41.2% of the women 3 years after surgery., Conclusion: Ectopic pregnancy involves a pathological fetomaternal interface. The leucocytic infiltrate in the area of implantation may be of secondary character and may cause gradual destruction of the ectopically positioned product of conception. The results of our study indicate a possible participation of the increased AT-CMI in the destruction of the ectopically located trophoblast. Persisting anti-trophoblast immunity may influence the occurrence and course of further gravidities.

Objective: To determine the success rate of methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable and unruptured ectopic pregnancy patients., Study Design: This prospective clinical study was carried out on 161 patients with suspected tubal ectopic pregnancy. Fourty-six patients have been accepted as ruptured ectopic pregnancy with hemodynamically stable and 115 patients have been accepted as unruptured ectopic pregnancy. All patients diagnosed with ectopic pregnancy were treated by single dose (50 mg/m2) methotrexate if they have stable hemodynamia and fulfill the criteria of methotrexate treatment. Weekly beta-hCG level was measured and if this level was under 10 IU/L, the treatment has been accepted as successful. Mann-Whitney and Fisher's exact tests were used (SPSS, 10.0) for statistical analysis., Results: The success rates of methotrexate treatments in ruptured ectopic pregnancy patients with hemodynamically stable and in patients with unruptured ectopic pregnancy were observed as 62% and 81%, respectively (P < 0.001). The treatment was successfully completed in all expectant management patients., Conclusion: Although methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable patients is not as successful as in unruptured ectopic pregnancy group, 62% success rate in this group may promise a treatment choice before surgery application.

A 33-year-old pregnant woman presenting with low abdominal pain was diagnosed with left-sided tubal extra-uterine pregnancy, which was surgically removed.

Objective: Tubal pregnancy remains an important cause of maternal morbidity and mortality. We sought to quantify the relationship of time between symptom onset and treatment and the risk of tubal rupture., Methods: We reviewed inpatient, clinic, and physician office charts of 221 women with tubal pregnancy. We assessed the conditional risk of rupture with passing time and other factors related to rupture., Results: Time between symptom onset and treatment varied from 3 hours to 66 days with an average of 7 days. There was a 32% rupture rate. The conditional risk of rupture was highest within the first 48 hours of symptom onset (5-7%). The risk dropped, leveled off, and remained fairly steady at approximately 2.5% per 24 hours of untreated symptoms. Classic tubal pregnancy signs, symptoms, and tests were not helpful in predicting rupture., Conclusion: The rate of rupture is highest in women with the shortest times between symptom onset and treatment. With passing time, the risk declines, but remains steady despite women's getting into care., Level of Evidence: II-2

Background: The use of conservative surgical techniques to treat ectopic pregnancies has been reported to increase the rate of incomplete trophoblastic tissue removal and subsequent regrowth., Case: A persistent ectopic pregnancy occurred in a woman previously treated with laparoscopic linear salpingostomy for an ampullary ectopic pregnancy. Repeat laparoscopy was performed, and bleeding from an ovarian implantation site was treated with resection of the trophoblastic site and electrocautery. A repeat linear salpingostomy was also performed at the site of the prior salpingostomy, where trophoblastic tissue also persisted., Conclusion: This is the first known case of hemorrhage from the probable secondary ovarian implantation of persistent trophoblastic tissue. A repeat conservative surgical procedure to treat persistent ectopic pregnancies and maintain potential fertility is advocated. This case also serves as a reminder to diligently examine all areas of the pelvis for the possible secondary implantation of persistent trophoblastic tissue should reoperation be necessary.

We report a case of heterotopic pregnancy in a woman who had not undergone in vitro fertilization or any other reproductive assistance. The patient failed to mount a tachycardic response to hemorrhagic shock. Bradycardia is a well-established phenomenon in the setting of hemoperitoneum and particularly with ruptured ectopic pregnancy. This is a case of heterotopic pregnancy with relative bradycardia in a woman without predisposing factors for heterotopic pregnancy. We make suggestions on avoiding common pitfalls in the emergency department diagnosis of heterotopic pregnancy. We also address the similar clinical presentations of heterotopic pregnancy and intrauterine pregnancy with ruptured corpus luteum cyst.

Management of severe ovarian hyperstimulation syndrome (OHSS) includes hospitalization for fluid and electrolyte management. Abdominal paracentesis is also used as minimally invasive form of management in selected cases of severe OHSS following ovulation induction. However, if pregnancy ensues, the syndrome persists for a longer period, and the clinical manifestations of severe OHSS could mask the picture of a bleeding gestational sac. It could be easily overlooked unless the possibility of an ectopic pregnancy is kept in mind in cases of severe OHSS exacerbated by early pregnancy with or without a previous ectopic pregnancy history. We report a case of severe OHSS with simultaneous bilateral tubal pregnancy following intrauterine insemination (IUI). A 31-year-old woman with polycystic ovarian disease developed severe OHSS during the therapeutic course of IUI. An emergent exploratory laparotomy was performed 14 days after admission, and the operative findings showed persistent profuse bleeding from the bilateral fimbrial ends with marked enlargement of the ampullary portions. A linear salpingotomy was performed by a longitudinal incision along the area of maximal distension of the dilated fallopian tubes to preserve her fertility. We recommend that in cases of severe OHSS exacerbated by early pregnancy, serial serum beta-hCG and transvaginal ultrasound follow-up may be necessary due to the potential association of severe OHSS in pregnancy with an ectopic pregnancy.

Objective: To investigate the effects of genital tract ureaplasma urealyticum (UU), chlamydia trachomatis (CT) and cytomegalovirus (CMV) infection on tubal pregnancy., Methods: One hundred and twenty eight women with tubal pregnancy (study group) and 50 women with ovarian cysts and without tubal pregnancy (control group) were recruited in this study. Cervical secretion and salpinx tissue samples were collected to detect UU, CT and CMV DNA using PCR., Results: (1) UU DNA was detected in cervical secretions from 56 (43.8%) and 10 (20.0%) women in the study group and control group, respectively. In salpinx tissue specimens, it was detected from 48 (37.5%) and 5 (10.0%) women in the study and the control group, respectively. Both of the differences between the study and control groups were very significant statistically (P < 0.01). (2) CT DNA was detected in cervical secretions from 35 (27.3%) and 5 (10.0%) women in the study and control group, respectively. In salpinx tissue specimens, it was detected from 34 (26.6%) and 3 (6.0%) women in the study group and control group, respectively. Both the differences between the two groups were significant (P < 0.05). (3) CMV DNA was detected in cervical secretions from 21 (16.4%) and 3 (6.0%) women in the study group and control group, respectively. In tubal tissue specimens, it was detected from 25 (19.5%) and 2 (4.0%) women in the study group and control group, respectively. Both the differences between the two groups were significant (P < 0.05). (4) Pelvic adhesion occurred in 70.6% women with UU DNA positive, 77.3% women with CT DNA positive, and 16.7% women with CMV DNA positive. While it occurred in 13.3% of women without any of three DNAs detected., Conclusions: Genital tract infections of UU, CT and CMV in women with tubal pregnancy were significantly more common than in those without tubal pregnancy. UU, CT and CMV infection may be associated with an increased incidence of tubal pregnancy. Pathological change in genital tract caused by UU and CT infection may be more severe than that by CMV infection.

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.

Background: Simultaneous or concomitant bilateral adnexal pathology is rare. But simultaneous tubal pregnancy and twisted ovarian cyst is even rarer., Case: A 25-year-old woman, gravida 2, parity 0, presented with acute abdomen after 12 weeks of amenorrhea. Simultaneous right tubal pregnancy and twisted left ovarian cyst were intraoperatively diagnosed. Right salpingostomy and left salpingo-oophorectomy were performed. The follow-up serum beta-hCG was negative at the nineteenth postoperative day. She was well at discharge and throughout the 4-week follow-up period., Conclusion: Although simultaneous or concomitant bilateral adnexal pathology is uncommon, a careful assessment of both adnexa is mandatory especially in the cases with inconsistent site of symptom and pathology in order to avoid undiagnosed simultaneous pathologies that may be missed.

A case is described of advanced tubal pregnancy associated with severe fetal growth restriction delivered at 27 weeks. The placenta was implanted on the salpinx and on the uterotubal angle. Progressing tubal pregnancy and its placental histological characteristics could be a model of placental dysfunction typically associated with intrauterine growth restriction.

Background: Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles., Case: We report such a case in a 28-year old para 0, gravida 1 woman with no known risk factors. The ectopic pregnancy was diagnosed after rupturing at 11 weeks, 4 weeks after diagnosis of the intrauterine pregnancy, and resected via laparotomy. A healthy baby was delivered without complications at 40 weeks gestation., Conclusion: Heterotopic pregnancy is possible with natural conception and the survival of the intrauterine fetus is feasible.

Background: Several risk factors for ectopic pregnancy (EP) have been identified, but the site of implantation of EP has been little studied., Methods: A total of 1800 surgically treated EP was registered between January 1992 and December 2001 in the Auvergne EP register and the women concerned were followed up. In this large population-based sample, we studied the distribution of EP sites, immediate complications, determining factors, and subsequent fertility., Results: EP sites were interstitial (2.4%), isthmic (12.0%), ampullary (70.0%), fimbrial (11.1%), ovarian (3.2%) or abdominal (1.3%). No cervical pregnancies were observed. Complications and treatment depended on the site of EP. In multivariate analysis, the only risk factor associated with EP site was current use of an intrauterine device (IUD), which was more frequent in distal EP. The 2 year cumulative rate of subsequent spontaneous intrauterine pregnancy (IUP) increased progressively from interstitial to ovarian EP. Fair concordance (weighted kappa = 0.31) was observed between the sites of two successive EP if they were homolateral., Conclusion: In addition to providing an accurate description of the sites of implantation of EP, this study shows that current IUD use 'protects' against interstitial pregnancies, which are the most difficult to manage. It shows that subsequent fertility tends to be higher in women with distal EP.

Ectopic pregnancy has been increasing in frequency over the past 2 decades. The sudden rupture of a fallopian tube caused by ectopic pregnancy can lead to hemorrhagic shock and death if not diagnosed and treated in a timely fashion. The emergency physician is often the health professional that is called on to make the diagnosis and coordinate timely and effective intervention. The first step in the diagnosis of ectopic pregnancy is demonstration of pregnancy by means of a rapidly performed and sensitive qualitative urine test for the beta-subunit of human chorionic gonadotropin (beta-hCG). A negative urine pregnancy test result will generally be used to exclude ectopic pregnancy from further consideration. The following is a report of a patient presenting to an emergency department with hypovolemic shock in conjunction with 2 negative urine beta-hCG analysis results and a quantitative serum beta-hCG level of 7 mIU/mL, a value less than the lower limit of detection for the highly sensitive qualitative urine and serum tests. This case report demonstrates the importance of further consideration of the diagnosis of ectopic pregnancy in the setting of a negative urine pregnancy test result.

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 investigate the correlation between the free fluid area detected with ultrasonography and the internal hemorrhage volume observed during operation in tubal pregnancy., Methods: The correlation between the size of free fluid area measured by ultrasound and the volume of internal hemorrhage collected during operation among 201 cases of tubal pregnancy was analyzed. The difference of internal hemorrhage between tubal abortion and tubal pregnant rupture was analyzed too., Results: A positive correlation was observed between the size of free fluid area measured by ultrasound and the internal hemorrhage volume (r = 0.7712). A statistically significant difference of internal hemorrhage volume was found between tubal abortion and tubal pregnant rupture with a free fluid area in the range of 0.1-10.0 cm., Conclusion: The volume of internal hemorrhage caused by tubal pregnancy can be estimated according to the free fluid area detected with ultrasonography.

Interstitial (cornual) pregnancy is a rare form of ectopic pregnancy that can be difficult to diagnose both clinically and ultrasonographically. However, early detection is essential to avoid fatal outcome. We report a case of interstitial/cornual ectopic pregnancy. The patient presented with uterine rupture over the cornual region resulting in catastrophic bleeding. The risk factors, clinical features and ultrasonographic signs are reviewed.

A case is reported of spontaneous ectopic pregnancy in a non patent fallopian tube of a patient with a contralateral unicornuate uterus without rudimentary horn. A hemoperitoneum, due to the rupture of the tube, occurred with a HCG level of 48 I.U./l. A laparoscopy was therefore performed and the fallopian tube removed.

This is the report of a patient, that had without using any assisted reproduction technology (ART) the rare event of a heterotopic pregnancy. After verifying the intrauterine pregnancy by ultrasound, the ectopic tubal pregnancy (EP) was detected at an emergency abdominal surgery as the cause of an intraabdominal hemorrhage. After removal the further pregnancy was uncomplicated.

A case of 35 year old gravida 4 para 2(+1) woman with heterotopic pregnancy is presented. She had total salpingectomy for the ectopic pregnancy and spontaneous vaginal delivery of a 3.25 kg live female infant of the intrauterine pregnancy. The need to maintain a high index of suspicion and to intervene early to salvage the intrauterine pregnancy, and to prevent material morbidity and mortality associated with the ectopic pregnancy are emphasized.

Heterotopic pregnancy, defined as the coexistence of an intrauterine pregnancy and an ectopic pregnancy, occurs in approximately 1 in 100 pregnancies conceived by in vitro fertilization (IVF), particularly when multiple embryos are transferred into the uterus. The ectopic gestation of the combined pregnancy usually occurs within the ampulla of the fallopian tube. If it implants within the interstitial portion of the fallopian tube, however, the resulting interstitial pregnancy eventually can rupture through the uterus, leading to sudden, severe hemorrhage and maternal death. This article describes the rupture of an interstitial heterotopic pregnancy in a 37-year-old woman conceiving by IVF after bilateral salpingectomy. The interstitial pregnancy was removed by laparotomy to protect the intrauterine pregnancy from damage. Physicians should consider interstitial ectopic pregnancy as a cause of abdominal pain, even when a viable pregnancy occurs by IVF after salpingectomy.

Diagnosis of ectopic pregnancy continues to be an important challenge facing emergency physicians. The authors present a case of bilateral tubal ectopic pregnancy and discuss its clinical features and diagnostic difficulties. A review of the English-language literature on the subject is discussed. Suggestions are made on ways to increase diagnostic accuracy, reduce complications, and preserve future fertility in this group of patients.

We present the cases of two women with chronic ectopic pregnancies who presented with acute tubal rupture and hemoperitoneum despite negative beta-human chorionic gonadotropin (beta hCG) pregnancy tests. The appropriate screening use of beta hCG assays to ascertain pregnancy status, the mechanisms by which ectopic pregnancy may be seen with negative beta hCG tests, and the limitations of various assays are discussed. One patient, not initially believed to be pregnant, underwent computed tomography (CT) scan. Experience with use of CT scan in ectopic pregnancy diagnosis is limited; our case illustrates some of the possible CT scan findings. These cases illustrate the potential for ectopic pregnancy to rupture with low, if not undetectable beta hCG hormone levels, and consequently why it is not recommended to rely on quantitative beta hCG levels to guide the decision to proceed with ultrasound imaging.

We present a case of a 13-week pregnancy with a malformed fetus in a ruptured, non-communicating rudimentary horn. The patient, a 21-year-old woman with pelvic and right-sided abdominal pain, was admitted to the gynecology clinic of our institution. A ruptured rudimentary horn pregnancy was diagnosed by ultrasonography. The fetus in the gestation sac showed evisceration of the liver and intestines and an absent left femur. There was an amniotic band extending across the body of the fetus. The ruptured horn was excised by laparotomy. The factors associated with rudimentary horn pregnancy and related fetal abnormalities are discussed.

A case of non-progressive and earlier abdominal pregnancy, associated with an evolutionary tubal pregnancy is reported by the authors. This clinical situation is very rare, indeed, exceptional, because it concerns two successive and ectopic pregnancies. The poor obstetrical cover and the ineffectual supervision of the pregnancy explain in part these situations in our countries.

Objective: To investigate the factors influencing the choice of treatment for ectopic pregnancy and to compare the subsequent fertility rates of radical, conservative-surgical or medical treatments., Design: Population-based study of 835 ectopic pregnancies registered between 1992 and 1996., Setting: Auvergne Ectopic Pregnancy Register (France)., Sample: Four hundred and seventy-six women with tubal ectopic pregnancy who were not using contraception at the time of conception. Subsequent fertility was studied for the 291 women who attempted to conceive again., Methods: Comparison of reproductive outcomes according to ectopic pregnancy treatment. Cumulative fertility curves were calculated by the Kaplan-Meier estimator and compared by log rank test for univariate analysis and by Cox regression to take into account confounding variables., Main Outcome Measure: Recurrence and fertility rates after ectopic pregnancy., Results: The first treatment given was 'radical' for 178 women (37%), 'conservative-surgical' for 262 (55%), and 'medical' for 35 (8%). The treatment failed in 1% for radical treatment, 5% for conservative-surgical treatment, and 36% for medical treatment. The two-year cumulative rate of recurrence was 27% with no significant difference between treatments. For women with previous infertility factors (in particular diseased contralateral tube), the treatments differed significantly, with the rate of intrauterine pregnancy lower for radical treatment and higher for medical treatment than for conservative-surgical treatment. For women with no infertility factor, there was no significant difference between treatments., Conclusions: These results should be confirmed in a controlled trial. The results of this study provide the elements necessary to plan such a trial.

A rare case of a second ipsilateral ectopic gestation occurring in the stump of the cornua three years after total salpingectomy for ruptured ectopic pregnancy is presented.

Placental site nodule (PSN) is an asymptomatic benign proliferation of intermediate trophoblast from a previous gestation that failed to involute. It is most commonly found in the endometrium or endocervix; however, placental site nodule has recently been reported to occur at sites of ectopic gestation. This is the first case of PSN in the broad ligament in direct contact with the fallopian tube. The patient underwent surgery for an adenocarcinoma of the opposite tube. Microscopically and immunohistochemically, the lesion showed the characteristics of a proliferation of intermediate trophoblast.

The authors describe the case of a right tubal pregnancy of delayed diagnosis in a 31-year-old nullipara, who was submitted to voluntary termination during the 7th week of pregnancy and who presented a homolateral ovarian cyst. Two weeks later the patient presented pelvic pain and intraperitoneal fluid layer, while plasma beta-hCG was 1,262 IU/ml. The case history was complicated by recent termination surgery and presence of an ovarian cyst, but a plasma beta-hCG assay and transvaginal ultrasonography oriented the diagnosis towards a previously unrevealed heterotopic pregnancy. The fallopian tube and the ovarian cyst were removed by laparoscopy. The case points out to the fact that, though rare, heterotopic pregnancy must always be considered one of the possible complications of spontaneous pregnancy., (Copyright 2000 S. Karger AG, Basel)

The patient described in this report had bilateral hydrosalpinx due to pregnancies in both fallopian tubes, treated by laparoscopic resection. Histologically, both fallopian tubes revealed intratubal occlusion by degenerated, partially calcified chorionic tissue. An incidental finding was an intraluminal papillary epithelial tumor in one of the fallopian tubes. The clinical significance and complications of asymptomatic tubal ectopic pregnancy and the pathogenesis and biologic behavior of papillary epithelial tumors of the fallopian tube are briefly discussed.

Background: Because heterotopic pregnancy is rare, the presence of an intrauterine pregnancy tends to impede early diagnosis and definitive intervention for the ectopic component. Delay in diagnosing the condition and failure to proceed quickly with the requisite anesthesia and surgery can jeopardize both maternal well-being and survival of the intrauterine fetus., Case: A patient with heterotopic pregnancy carried the intrauterine pregnancy to term following first-trimester rupture of the tubal pregnancy, with hypovolemic shock., Conclusion: Prompt diagnosis, rapid fluid and blood resuscitation, heart-sparing anesthesia and gentle, expeditious surgery collectively contributed to the favorable outcome for the mother and surviving infant.

The presentation of acute abdominal pain in young women is not an unusual occurrence in casualty and gynaecology departments. Both acute appendicitis and ectopic pregnancy have to be considered and investigated, as these two conditions are accepted as the most common surgical causes of an acute abdomen. Difficulties in correctly identifying the cause of the pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. The case report presented here describes the extremely unusual occurrence of both these acute conditions happening simultaneously with the added complication of an ongoing twin pregnancy and it highlights the need to look beyond the most obvious diagnosis and always to expect the unexpected.

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.

Pelvic ultrasound and human chorionic gonadotropin assays are currently the standard methodology to detect tubal pregnancy. We report a case of infertility investigated by hysterosalpingography in which a clinically unsuspected chronic tubal pregnancy was identified with the predisposing factor of bilateral salpingitis isthmica nodosa. The radiographic findings of this very rare cause of tubal filling defect are shown.

To establish the diagnostic value of p53 and c-erbB-2 expression, forty-eight cases of endosalpinx hyperplasia were analyzed. p53 protein and c-erbB-2 oncoprotein expression was examined using an avidin-biotin peroxidase complex method. The accumulation of p53 protein and c-erbB-2 oncoprotein was used as objective evidence to support morphologic differential diagnosis of endosalpinx hyperplasia and early cancer. In all cases various forms of endosalpinx hyperplasia were seen. Only in 4 cases staining for p53 showed positive reaction without staining for c-erbB-2. In one case positive reaction for c-erbB-2 was showed and no expression of p53 protein was detected. It is concluded that immunohistochemical detection of the mutant p53 protein and c-erbB-2 oncoprotein might be useful tools in differential diagnosis among various forms of hyperplastic changes of endosalpinx. The presence of these markers may be associated with the risk of malignant transformation in various forms of the tubal hyperplasia.

Objectives: Ovarian tumors during pregnancy are rare event. Histologic subtypes and prognosis do not differ from tumors not associated with pregnancy, it seems however, that are more lesions of borderline malignancy and of low grade. An extremely rare of ovary adenocarcinoma coexisting with tubal pregnancy and planoepithelial cervical cancer of uterus has been discussed., Study Design: The patient S. D. age 39, was admitted to hospital with a diagnosis of peritonism, shock and general condition-hard. The patient was operated half an hour after admission to hospital. During laparotomy tubal pregnancy coexisting with ovarian carcinoma has been satisfied and total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy and staging was done., Results: Histopathological examination of surgical specimen revealed tubal pregnancy coexisting with bilateral focal ovarian adenocarcinoma (stage IC) and planoepithelial praeinvasive cervical cancer of uterus. Six cycles of PC chemotherapy are given. During second look laparotomy complete pathological response (pCR) was observed. The Ca-125 value was less then 35 IU/ml. Now the patient is followed for disease status every three month. Her health and is good., Conclusion: On the basis of the follow-up of the patient it seams that the coexistence of ovarian carcinoma with cervical cancer and tubal pregnancy neither accelerate the development of disease or make worse the prognosis.

Various studies demonstrated that there is no close correlation between the intratubal damage and the extent and type of pelvic adhesions. Moreover, the results of prospective studies on the prognostic value of salpingoscopy showed that the tubal mucosal status is the most important prognostic factor in terms of reproductive outcome. Salpingoscopy has modified the management of patients with tubal infertility, since the accurate evaluation of the tubal mucosa permits the selection of patients with a normal mucosa (34-42% of the patients with hydrosalpinx and 76-80% of those with periadnexal adhesions) who can benefit from tubal reconstructive surgery. In these patients the term pregnancy rate is 60% in case of hydrosalpinx and 70% in case of periadnexal adhesions.

The presence of a damaged tube has been suggested in recent studies to have a negative effect on in-vitro fertilization (IVF) outcome. Performing bilateral salpingectomy prior to IVF to maximize pregnancy rates may also result in unnecessary surgery. This case is also an example of the occurrence of interstitial pregnancy after salpingectomy. This unusual type of ectopic pregnancy must be kept in mind when evaluating a patient suspected of a possible early abnormal gestation after assisted reproductive technolologies.

The authors report the case of a 38-year-old woman who underwent total laparohysterectomy for multiple uterine leiomyomas and right adnexectomy following the intraoperative finding of a right tubal abortion.