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UDC 618.31-07
DIFFICULTIES OF DIAGNOSTICS OF RARE FORMS OF ECTOPIC PREGNANCY AFTER ART (CLINICAL CASES)
1 Altai State Medical University, Barnaul
2 Siberian Institute of Human Reproduction and Genetics, Barnaul V.V. Vostrikov1,2, E.A. Markova1, T.A. Kuznetsova1, T.I. Gorbacheva1
The description of clinical cases states possible difficulties in diagnostics of rare forms of ectopic pregnancy that occurred after implying assisted ancillary reproductive technologies. Difficulties of diagnostics of ectopic pregnancy after ART are explained by heterotopic localization, atypical clinical manifestations, anamnestic indication of absence of fallopian tubes.
Key words: ectopic pregnancy, assisted reproductive technologies, ectopic pregnancy, heterotopic pregnancy, IVF/ ICSI.
Assisted reproductive technologies (IVF / ICSI) are the most effective ways to overcome infertility. Annually in Russia, about 80-90 000 cycles of assisted reproductive technologies (ART) are carried out. One of the complications of IVF/ICSI is ectopic pregnancy, and the frequency of atypical localization of the fetal egg is much more frequent than in the population [1]. Special difficulties in diagnosing ectopic pregnancy are found in patients with uterine tubes removed. Over 16 years of work of the Siberian Institute of Human Reproduction and Genetics, treatment with assisted reproductive technologies has been performed in 6,512 patients. Ectopic pregnancy was diagnosed in 58 patients, which constituted 0.9%. Heterotopic pregnancy was diagnosed in 18 cases. In nine women with an ectopic pregnancy, the fallopian tubes were previously removed. In some cases, delayed diagnosis of a potentially dangerous complication is noted. Difficulties in diagnosing ectopic pregnancy after ART are explained by heterotopic localization, atypical clinical manifestations, an-amnestic indication of absence of fallopian tubes.
In the first clinical case, a variant of occurrence of repeated ecto-pic pregnancies of rare localizations in a patient after IVF is presented.
Patient E., 36 years old, due to secondary tubal infertility (uterine tubes removed earlier for ectopic pregnancies). Stimulation of ovulation in the cycle of assisted reproductive technologies was carried out. For transvaginal puncture, 10 oo-cytes fertilized with IVF of the husband's spermatozoa were obtained. On the third day of cultivation, three embryos of good and average quality were transferred to the uterine cavity. Drug support for the posttransfer period with progesterone preparations (morning 400 mg per day + 1
ml 2.5% oil progesterone solution). Two weeks after the transfer of embryos of HCG in the blood 17 mU/ml, which was regarded as a failure in the cycle of IVF and was the basis for the abolition of drug support of the luteal phase. On the 46th day after the embryotransfer, the patient had scanty, spotting discharge from the genital tract, pains in the lower abdomen with irradiation into the rectum. By ultrasound, in the uterine cavity the fetal egg was not detected, there was a bilateral increase in the ovaries due to a number of current-luteal cysts, a small amount of fluid in the posterior fornix (Figure 1). The patient is directed to the gynecological department on duty with suspicion of ectopic pregnancy.
Upon admission, a laparoscopy was performed. It was found: 400 ml of dark blood with clots in the small pelvis. Fallopian tubes absent, their stumps distinctly not expressed. On the broad ligament of the uterus on the right, near the corner, a cyanotic color of a bleeding site of 1.5 x 1.5 cm tissue was found (Figure 2), regarded as an abdom-
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Figure 1. Theca-luteal volumetric formation of the ovary.
inal pregnancy. The removal of the fetal egg with coagulation of the bed was carried out. Histological examination revealed chorionic villi. The postop-
erative period proceeded without complications. In the postoperative period, rehabilitation therapy was performed.
Figure 2. Abdominal pregnancy.
After 10 months, the patient was taken back to the ART program, during which three embryos were transferred to the uterus after thawing. Two weeks later, a low HCG blood value (16.5 mU/ml) was established, followed by a rise during two weeks to 127 mU/ml. Later, when observed against a background of well-being, the patient noted an episode of sharp pains in the region of the right appendages. By ultrasound of the uterine cavity,
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the fetal egg was not detected, the left ovary without peculiarities. Right ovary measuring 49 x 26 x 33 mm, with cavity inclusion 18 x 16 mm (Figure 3). In the parenchyma of the ovary, a fetal egg 17x19 mm with a yolk sac and amniotic cavity was visualized. A 3 mm embryo with a heartbeat was identified. The patient is directed to the gynecological department of an urgent hospital with suspicion of right-sided ovarian pregnancy.
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Figure 3. Ovarian pregnancy.
Laparoscopy: 150 ml of dark blood with clots in the abdomen. Fallopian tubes absent, stump of pipes not found. On the upper pole of the enlarged right ovary is visible a tissue with blood clots resembling a fetal egg. Resection of the ovary within the limits of healthy tissues. The total blood loss was 400 ml. In histological examination of the ovary tissue, trophoblast cells and chorionic villi were found on the background of hemorrhage into the yellow body. The course of the postoperative period without complications.
The presented example of the third and fourth ectopic pregnancies in one patient, in our opinion, shows the likelihood of an ectopic pregnancy and with absent fallopian tubes.
The second clinical case demonstrates the difficulties of diagnosing a heterotopic pregnancy after an IVF program in secondary tubal infertility.
Patient M. 31 years old, in connection with secondary tubal infertility (uterine tubes removed earlier for ectopic pregnancies), induction of ovulation in the cycle of in vitro fertilization. Three
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embryos were transferred to the uterine cavity. Medication support of the posttransfer period with progesterone preparations. Two weeks later, a biochemical pregnancy was diagnosed. At the subsequent observation on the 24th day after the transfer of embryos in the uterine cavity, one fetal egg with the embryo's heartbeat was found. A week later, against the background of growing weakness, nausea, dizziness, vomiting and moderate pains in the lower abdomen appeared. On examination: the skin is pale, wet, mild tachycardia and hypotension. The temperature is 37.6 ° C. The abdomen is soft, with signs of irritation of the peritoneum in the hypogastric region, more to the right. By ultrasound scanning, there was a progressive uterine pregnancy, bilateral ovarian enlargement due to a number of theca-luteal cysts, and an insignificant amount of free fluid in the right lateral flank (Fig. 4). In the analysis of blood leukocytosis - 18 x 10°, hemoglobin 118 g/l. The patient is directed to the surgical department of an urgent hospital with suspected acute appendicitis.
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Figure 4. Ultrasonic signs of free fluid in the abdominal cavity.
With suspicion of acute appendicitis, the patient is taken for laparoscopy. During the survey, it was found: up to 1500 ml of blood with clots in the abdominal cavity. When revising the pelvis, both uterine tubes are absent. The ovaries are enlarged due to a number of cystically altered yellow bodies. In the stump region of the right tube with the transition to the posterior wall of the uterus, a bleeding tissue of a cyanotic-purple color of 7x4x4 mm, regarded as an ectopic fetal egg, was found. The bed of formation is limited to the omentum, which is soldered to the corner and the posterior surface of the uterus. The rear arch is covered with spikes. The removal of the ectopic fetal egg and co-
agulation hemostasis of the bed was carried out. The diagnosis was confirmed histologically.
In the postoperative period, an anti-anemic and pregnancy prolonging therapy was performed. The patient was discharged on the 10th day with a progressive pregnancy.
Presented cases of rare forms of ectopic pregnancy after IVF - abdominal and ovarian - in patients with previously removed uterine tubes demonstrate the possibility of repeated ectopic pregnancies and the complexity of their diagnosis. The likelihood of such complications should be taken into account by conducting early pregnancy follow-up in women after using assisted reproductive technologies.
References
1. Kulakov V.I., Leonov B.V., Kuzmichev L.N. Treatment of female and male infertility. Assisted reproductive technologies. Moscow: MIA, 2005.
2. Nikolaeva M.G., Serdyuk G.V., Gorbacheva T.I., Belnitskaya O.A., Momot A.P. Effect of lym-phocytotherapy on fibrinolytic activity of blood and immune reactions and patients with reproductive losses in history. Gynecology, obstetrics and peri-natology. 2016; 15(5): 38-43.
3. Vartanyan E.V., Tsaturova K.A., Petukhova N.L., Markin A.V., Uskova M.A., Devyatova E.A. Endometriosis: Conservative treatment as part of preparation for infertility treatment using in-vi-tro fertilization. Doctor.Ru. Gynecology Endocrinology. 2015; 1(102): 21-25.
4. Nazarenko T.A., Korsak V.S. Estrogens in reproductive medicine. Мoscow: MEDpress-In-form; 2016.
Contacts
Corresponding author: Vostrikov Vyacheslav Val-erievich, Candidate of Medical Sciences, Associate Professor of the Department of obstetrics and gy-necology with the course of FVE, Altai State Medical University, Barnaul. 656038, Barnaul. Lenina Prospekt, 40.
Tel.: (3852) 566869. Email: [email protected]
Markova Elena Aleksandrovna, Candidate of Medical Sciences, Associate Professor of the Department of obstetrics and gynecology with the course of FVE, Altai State Medical University, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201254. Email: [email protected]
Kuznetsova Tatyana Aleksandrovna, Candidate of Medical Sciences, Associate Professor of the Department of obstetrics and gynecology with the course of FVE, Altai State Medical University, Barnaul.
656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201254. Email: [email protected]
Gorbacheva Tatyana Ivanovna, Candidate of Medical Sciences, Associate Professor of the Department of obstetrics and gynecology with the course of FVE, Altai State Medical University, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201254. Email: [email protected]
