OBJECTIVE: While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vNOTES is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic salpingectomy for the surgical management of ectopic pregnancy.
METHODS: Case control study SETTING: A London University hospital PATIENTS: Women with ectopic pregnancy unsuitable for medical management who underwent surgical management INTERVENTION: 25 cases of vNOTES vs 25 conventional laparoscopic salpingectomy MEASUREMENTS AND MAIN RESULTS: The mean patient age (29.7±53 vs 31.4±6.7 days), parity (1.2±1.1 vs 1.6±2.1), BMI (26.7±5.3 vs 27.2±5.4 kg/m3), gestation age (8.44±2.1 vs 7.3±1.7 weeks) and βhCG levels (3725.4±3674.8 vs 4376.5±6493.4 IU/litre) were comparable (p>0.05, t test) between patients having vNOTES vs conventional laparoscopic salpingectomy. While estimated blood loss was similar (218.2±491.7 vs 173.5±138.7 mls)(p>0.001), vNOTES patients had statistically shorter duration of surgery (35.8±14.4 vs 75.8±19.7 mins)(p<0.001, t test) and length of stay (median: 11.5 vs 19.7 hours)(U=72, p<0.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%) and median Visual Analogue Score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0)(U=75, p<0.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8±4.3 vs 17.1±8.2 days)(p<0.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia.
CONCLUSIONS: Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain and more rapid recovery, which help mitigate higher cost incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomised studies are needed.

A focal serous tubal intraepithelial lesion (STIL) is a rare lesion found on fallopian tubes that are characterized by atypical epithelial cells exhibiting morphological abnormalities with the accumulation of mutant p53 proteins. The p53 gene is a tumor suppressor gene, and when mutated gives rise to mutant p53 proteins that promote cancer cell growth and survival. We present a case of a 47-year-old gravida 2, para 2002 (G2P2) female who presented to the outpatient clinic with bilateral lower quadrant abdominal pain and back pain of four years\' duration. The patient\'s history included endometriosis with lysis of adhesions and gynecological laparoscopy, leiomyomata, infertility, ovarian cyst, dysmenorrhea, two full term births, and Essure implants used for contraception; her family history included maternal grandfather with breast cancer. Multiple fibroids and endometriosis were confirmed on pelvic ultrasound (US) and magnetic resonance imaging (MRI). Due to worsening pain, the patient chose to have an elective hysterectomy and Essure implant removal with bilateral salpingectomy. The postoperative pathology report revealed a right fallopian tube with a STIL. Multiple genetic mutations are known to contribute to the development of STILs including p53 and the breast cancer gene (BRCA). There are two BRCA genes, BRCA1 and BRCA2, that have many functions including producing proteins that repair damaged DNA. When mutated, this allows cells to divide and change rapidly, leading to certain types of cancer. Given the patient\'s family history of breast cancer, the patient was tested for BRCA1 and BRCA2 for which the results were negative. However, even without having a BRCA mutation that is known to increase the risk of ovarian, fallopian tube, and peritoneal cancers, STILs continue to pose an increased risk of high-grade serous ovarian carcinoma (HGSOC). This case demonstrates the reasoning behind prophylactic salpingectomies alongside hysterectomies and the significance of the postoperative pathology report from gynecological procedures.

Heterotopic pregnancy (HP) is the coexistence of living or dead intrauterine pregnancy, single or multiple, and extrauterine pregnancy located in the oviduct, ovary, uterine corner, cervix or peritoneal cavity. This condition is very rare (1:30 000 pregnancies). HP constitutes a rare obstetric condition. Its occurrence after natural conception is sparsely documented in the literature. Here in, we present a case of a 27-year-old primeparous women who presented at 18 weeks with features of ruptured ectopic pregnancy. Initial ultrasonographic imaging showed an intrauterine pregnancy corresponding to 18 weeks. It also revealed a floating fetus with significant collection of fluid in the pouch of Douglas, retroceacal recess and both hepatocellular recess. An emergency explorative laparotomy was done where right salpingectomy was performed. She was later followed up to term and delivered by elective cesarean section successfully. A brief narrative of the challenges in the management, clinical presentation and limitation in the management is highlighted in the present case report. Key message: Heterotopic pregnancy can occur in natural conception irrespective of usage of ovulation induction. Routine early pregnancy ultrasound can promote early detection with prompt surgical intervention to mitigate its complications.

The sterilization failure rate of a total bilateral salpingectomy is unknown. After a total bilateral salpingectomy, spontaneous intrauterine pregnancy is extremely rare; only four cases have been documented. This case report describes a 34-year-old G4P1213 with a history of bilateral salpingectomy who was found to have a viable intrauterine pregnancy. The pregnancy was continued and ended in a repeat cesarean section. At the time of surgery, a left tubal remnant was noted. While the patient was originally reported to have a complete salpingectomy, the evidence of a tubal stump makes this an unintended partial salpingectomy. It is theorized that dense pelvic adhesions at the time of the left salpingectomy increased the likelihood of sterilization failure. This is the first case report to evaluate the pelvic cavity after an intrauterine pregnancy following a reported complete bilateral salpingectomy. Patients should be counseled on the risk of ectopic and intrauterine pregnancy following a bilateral salpingectomy.

Isolated tubal torsion of the hydrosalpinx is a rare occurrence with a varied clinical presentation, presenting a diagnostic challenge. We present a case involving the isolated torsion of the right hydrosalpinx in a 33-year patient with a history of bilateral tubal ligation who presented with an acute abdomen. Based on ultrasound and clinical findings, an initial diagnosis of ovarian torsion was considered. However, escalating pain severity led to diagnostic laparotomy, revealing torsion in the right hydrosalpinx. Subsequent right salpingectomy was done, and as the patient had undergone tubal ligation, preventive left salpingectomy was also performed. Both ovaries were preserved. The patient experienced an uneventful recovery. A literature review uncovered fewer than 50 reported cases of unilateral or bilateral isolated fallopian tube torsion post-tubal ligation. This case underscores the diagnostic challenges associated with isolated tubal torsion and emphasizes the crucial role of early surgical intervention in preventing morbidity and preserving ovaries.

An ectopic pregnancy occurs when the fertilized egg is implanted and develops outside the endometrium, i.e. in the fallopian tubes, cervix, ovary, or abdomen. It commonly presents with a history of amenorrhoea, lower abdominal pain, and slight vaginal bleeding. The fallopian tube is the most typical location for ectopic pregnancy. Two percent of reported pregnancies are ectopic pregnancy. Ectopic pregnancy remains a public health threat for women in reproductive age, and a major cause of maternal mortalities in the first trimester. In East Africa, these reports are limited, despite a great need for documentation addressing key considerations for diagnosis and management of ectopic pregnancy in these resource limited settings. In this case study, we report on 26-years-old female Gravida 5 Para 4 Living 4, who reported history of amenorrhoea for 3 months complaining of slight per vagina bleeding and lower abdominal pain for 5 days more marked at left iliac region along with generalized weakness for 2 weeks. Her vitals were stable. Pelvic ultrasound revealed empty uterus and live fetus at the left adnexa corresponding to 14 weeks 6 days with minimal free fluid in the Douglas Cul-de-sac. The patient\'s final diagnosis was live extra-uterine pregnancy at 14 weeks 6 days that was managed by emergency laparotomy with salpingectomy. The patient recovered completely after surgery and was discharged in a stable condition. Ectopic pregnancy still remains one of the major causes of maternal morbidity and mortality. Early diagnosis and referral in hemodynamically state along with use of minimal access surgery or management can change the scenario of ectopic pregnancy in the developing world. Late attendance to first visit clinics is still a major concern in low resource limited settings as this could have been picked early and intervened. Key message: Management of broad ligament ectopic pregnancy in the second trimester is still challenging especially in low resource settings where the clients do not attend clinics and because of unavailability of ultrasound machines to diagnose it.

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Spontaneous heterotopic pregnancy is a rare clinical condition which is a potentially dangerous condition where at least two pregnancies are present simultaneously at different implantation sites and only one is located in the intrauterine cavity. It is a life-threatening condition with an incidence estimated as 1 in 30,000 natural conceptions. Being rare it\'s challenging to diagnose such conditions due to complex clinical and laboratory findings. In view of the survival of maternal as well as intrauterine pregnancy, a high index of suspicion leading to timely diagnosis and appropriate intervention is needed. We are reporting a case of a 28-year-old female with heterotopic pregnancy at 8 weeks of gestation following natural conception diagnosed by ultrasound and managed successfully by laparoscopic salpingectomy. Intrauterine pregnancy was continued normally till term with no complications. Hence, with timely diagnosis and early intervention, maternal and fetal survival is possible.
UNASSIGNED: case reports; ectopic pregnancy; laparoscopy; ultrasound.

BACKGROUND: Heterotopic pregnancies are increasing in incidence with the advent of rising prevalence of in vitro fertilization and embryo transfer (IVF-ET) globally. Although rare, this condition is a serious potentially life-threatening gynaecological complication.
METHODS: We present the case of a 36-year-old Ghanaian woman who conceived following IVF and presented two weeks after confirmation of intrauterine gestation with sudden onset lower abdominal pain. A diagnosis of ruptured heterotopic pregnancy was made, laparotomy and salpingectomy was done followed with further management of the intrauterine gestation.
CONCLUSIONS: To the best of our knowledge, this is the first reported case of heterotopic pregnancy in Ghana. A high index of suspicion for heterotopic pregnancy is required even in the presence of a confirmed intrauterine gestation following IVF-ET.