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PubMed1976

Ectopic pregnancy associated with the intrauterine device: a study of seventy cases.

Seventy cases of ectopic pregnancy associated with an IUD comprised 10% of all ectopics in a 9 year period. This increased to 15% in the last 19 months as more IUD's were in use. In two thirds of the ectopics the IUD had been in situ more than 1 year. Unusual bleeding and cramping attributed to the IUD obscured the diagnosis and resulted in removal or replacement of the IUD in over one half the cases 1 to 8 weeks before surgery. The episodic nature of the abdominal hemorrhage in two thirds of all ectopics resulted in surgery on day 44 average gestational age. The IUD is probably not causal in ectopic pregnancy but does not protect the predisposed patient from ectopic pregnancy which should be suspected in any patient with an IUD who has irregular bleeding and abdominal pain.

Adult↗
PubMed1983

beta-Subunit of human chorionic gonadotropin, ultrasound, and ectopic pregnancy: a prospective study.

This prospective study shows that the beta-subunit of human chorionic gonadotropin (beta-hCG) "screen" and ultrasound provide for nearly 100% clinical accuracy in diagnosing ectopic pregnancy in suspected cases. During the 14 months from February, 1981, to April, 1982, 81 consecutive patients believed to have ectopic pregnancies were screened. Fifty-six had a negative beta-hCG screen, thus ruling out early pregnancy complications. No false negative results were found. Twenty-seven patients had a positive screen, and 16 of these had an ectopic pregnancy. Twenty of the 27 patients with a positive beta-hCG screen underwent pelvic ultrasound examination. All of those with a positive beta-hCG screen and no intrauterine pregnancy on ultrasound had ectopic pregnancies. With the use of these clinical aids, morbidity and tubal damage are reduced because delay in operating upon those with ectopic pregnancy is avoided. Unnecessary operation is avoided in those patients who do not have an ectopic pregnancy.

Adolescent↗
PubMed1984

Factors influencing fertility after ectopic pregnancy.

Seventy-one cases of ectopic pregnancies that had been treated by salpingectomy or salpingo-oophorectomy were evaluated. All patients were attempting pregnancy after the surgical procedure. During a follow-up that ranged from 3 to 13 years the overall conception rate was 62%. Excluding the ectopic pregnancies, the uterine pregnancy rate was 52%. The repeat ectopic pregnancy rate was 12.6%. The uterine pregnancy rate was higher for patients treated by salpingectomy (p less than 0.02). The repeat ectopic pregnancy rate was similar after salpingectomy and salpingo-oophorectomy. The uterine pregnancy rate in women with a previous history of pelvic inflammatory disease was poor (19%), and those patients had a high incidence of recurrent ectopic pregnancy (27%). The pregnancy rate was higher in women who were under age 25 at the time of the ectopic pregnancy. Parity did not have an effect on future fertility.

Adolescent↗
PubMed1989

The use of transvaginal ultrasonography in the diagnosis of ectopic pregnancy.

Despite advances in diagnosis made by the introduction of serum beta-subunit of human chorionic gonadotropin determinations and transabdominal ultrasonography, ectopic gestations still present a major diagnostic challenge. The increased resolution of the transvaginally introduced high-frequency ultrasound transducer probes seems to solve this diagnostic problem. In this study 145 patients were referred for ultrasonographic workup because of a suspected ectopic gestation. In 38 patients a diagnosis could be made with classical transabdominal scanning. One hundred seventeen patients required additional transvaginal scanning with a 5.0 and a 6.5 MHz probe. In 98 patients a diagnosis was made during the first transvaginal scan; nine patients were rescanned within 3 days for the final diagnosis. In 56 patients, ectopic pregnancy was successfully ruled out by transvaginal scanning. Thirty-nine ectopic pregnancies were diagnosed. Only one false-positive identification was made. The sensitivity of diagnosing ectopic pregnancy by high-frequency transvaginal sonography was 100%; the specificity was 98.2%. The positive predictive value of this method was 98%, and the negative predictive value was 100%. The rate of the beating fetal heart was seen in the tube (23%). The high number of unruptured tubal pregnancies in this series (66%) suggests the possibility of an early diagnosis that may have therapeutic implications. The use of higher-frequency transvaginal transducer probes improves the diagnosis of the ectopic gestation.

Diagnosis, Differential↗
PubMed1990

Reevaluation of the role of culdocentesis in the management of ectopic pregnancy.

Culdocentesis has been used routinely in the evaluation of ectopic pregnancy. To determine whether culdocentesis continues to play an important role, we reviewed the operative findings of 297 women undergoing an operative procedure because of ectopic pregnancy. Culdocentesis was performed before surgery in 252 cases. Of those, 210 (83%) had positive test results and 42 (17%) had negative results. Positive results accurately predicted a ruptured ectopic pregnancy in 50% of cases, whereas negative test results were predictive of an unruptured ectopic pregnancy in 58% of cases. Six patients without an ectopic pregnancy underwent unnecessary laparotomy because of positive culdocentesis test results, whereas 27 patients who were discharged from the emergency room after negative test results were obtained subsequently were found to have ectopic pregnancies. The results of this study imply that culdocentesis is of limited value in a clinical setting in which sensitive and rapid testing and pelvic ultrasonography are used.

False Negative Reactions↗
PubMed1991

Recurrence of ectopic pregnancy: the role of salpingitis.

We evaluated the role of salpingitis on the recurrence of ectopic pregnancy from a historical cohort of 2501 women who had undergone laparoscopic examination for acute salpingitis. We used pregnancy (N = 2899) as the unit of analysis and a modified conditional logistic regression to estimate a pairwise odds ratio as a measure of the recurrence of ectopic pregnancy. Among the second or higher order of pregnancy, the recurrence was 21.7%. For pregnancies with a prior uterine pregnancy, the ectopic pregnancy rate increased with prior salpingitis scores constructed from a combination of prior salpingitis episodes and severity (0 score, 2.7%; 1 to 2 scores, 4.8%; and greater than or equal to 3 scores, 12.1%). For those with a prior ectopic pregnancy, the rate did not increase with prior salpingitis scores (score 0, 20.0%; score 1 or 2, 19.2%; and score greater than or equal to 3, 26.9%). The adjusted pairwise odds ratio was 2.2 and was practically unchanged (2.1) after additional adjustment with prior salpingitis scores. These findings confirm salpingitis as a risk factor for first ectopic pregnancy, but once a woman had an ectopic pregnancy, previous salpingitis might not add any incremental risk.

Adult↗
PubMed1983

Ectopic eruption of the maxillary first permanent molar: etiologic factors.

For clinical handling, it is important to determine whether any etiologic factors, alone or in combination, are of more importance than others in causing ectopic eruption of a maxillary first permanent molar. Etiologic factors involved in ectopic eruption of maxillary first permanent molars were investigated in 129 children with a mean age of 8.6 years. Ninety-two children (fifty-eight boys and thirty-four girls) had ectopic eruption and thirty-seven children served as controls and were matched by age and sex. Two types of ectopic eruption could be distinguished: a reversible type in which the permanent molar frees itself and an irreversible type in which the permanent molar remains in a locked position. Measurements were made on lateral head films, orthopantomograms, and dental casts. For 104 subjects all variables could be measured. Data was analyzed by discriminant analysis. Children with irreversible ectopic eruption had significantly larger permanent molars and a more pronounced mesial angle of eruption. A tendency toward a shorter maxilla was also found. No significant difference was found between sides with reversible ectopic eruption and sides with normal eruption. From the discriminant analysis between groups and all variables investigated, 90.7 percent of the cases could be correctly classified into groups. This study indicates that sufficient space may be gained for the premolars if the mesial tipping of the first molar is corrected, despite the tendency toward a shorter maxilla and larger than normal permanent molars.

Cephalometry↗
PubMed1979

Effect of the venereal diseases epidemic on the incidence of ectopic pregnancy -- implications for the evaluation of contraceptives.

This paper identifies a basis for quantifying the risk of ectopic pregnancy in pregnancy seekers and in users of the major means of contraception, with and without prior tubal infection. The doubling, in U.S. in recent years, of both numbers of ectopic pregnancies and the prevalence of nonsurgical sterility is correlated with the epidemic of gonorrhea and other sexually transmitted, salpingitis-producing diseases. The risk of ectopic pregnancy in women who have once had salpingitis is shown, on the basis of Weström's landmark prospective study and many retrospective studies, to be approximately 10-fold that of normal women. Fertilization-preventing contraceptives reduce uterine and ectopic pregnancies in the same proportion and in both categories of users--that is, in normal-risk and high-risk (post-salpingitis) women. Intrauterine contraceptives, however, markedly reduce uterine pregnancies, but have little effect on the incidence of ectopic pregnancy. Among IUD users, therefore, the incidence of ectopic pregnancy will be disproportionately great in relation to the fraction of high-risk women in the population of users. This disproportionate influence of prior salpingitis may confuse the comparative evaluation of contraceptive safety because the proportions of normal-risk and high-risk women probably vary widely, since public health data show extremely wide geographic differences in the incidence of gonorrhea -- the best known but not the only sexually transmitted, salpingitis-producing disease.

Contraception↗
PubMed1990

Utility of an algorithm to diagnose ectopic pregnancy.

In recent years, algorithms have been proposed to evaluate ectopic gestations. To determine the usefulness of an algorithm for a large county hospital, a surveillance project was initiated. During 2 years, 4045 women were screened in the emergency room for pregnancy. Of these, 1648 (41%) were noted to be pregnant, initially detected by rapid enzyme immunoassay for urinary human chorionic gonadotropin, and later confirmed using quantitative radioimmunoassay for serum human chorionic gonadotropin. Within this group, 249 women were diagnosed with ectopic pregnancies. Hemoperitoneum was discovered by culdocentesis in 128 of 249 cases of ectopic gestations, all operated upon acutely. A discriminatory zone for ultrasound was diagnostic of ectopic pregnancy in only 33 cases, as the majority of women presented with human chorionic gonadotropin levels below 6500 mIU/ml. Uterine curettage performed when abnormal serial levels of chorionic gonadotropin were observed detected an additional 46 cases. Early diagnosis permitted treatment prior to tubal rupture in 147 instances with conservation of the fallopian tube in 125 (50%). We conclude: (1) even in a busy county emergency room, algorithms are useful for expediting the diagnosis of ectopic pregnancy; (2) when ectopics are diagnosed early, conservative tubal surgery is possible in many patients.

Algorithms↗
PubMed1993

Reproductive performance following a second ectopic gestation.

OBJECTIVES: Our purpose was to determine the obstetric outcome following a second ectopic gestation in women actively trying to conceive, with a review of the literature. METHODS: Charts of 37 patients coded for having at least two ectopic pregnancies between 1986 and 1989 were reviewed. Duration of follow-up ranged from 7 months to 7 years with a mean follow-up time of 25 months. RESULTS: We report a 45.4% intrauterine pregnancy rate, 27.3% live birth rate, and 36.4% recurrent ectopic pregnancy rate. Review of the literature shows an intrauterine pregnancy rate of 26-50%, live birth rate of 25-31.2%, and recurrent ectopic pregnancy rate of 7.7-40%. CONCLUSIONS: Four of five studies report the risk of a third ectopic gestation is less than an intrauterine gestation. This may prove helpful in counseling patients with a history of recurrent ectopic gestation in choosing IVF or attempting conception naturally.

Adult↗
PubMed1980

Plasma hCG and ultrasound in suspected ectopic pregnancy.

The value of plasma hCG determinations (based on the recognition of beta-subunit of hCG) and ultrasound was examined in 48 cases of suspected ectopic pregnancy. In 11 patients with the final diagnosis of ectopic pregnancy (23%), the plasma hCG was clearly subnormal (0.37-3.96 IU/ml), with only one exception, where a normally developed fetus was operated from the fallopian tube (hCG 21.1 IU/ml in the 8th wk). The plasma hCG lvels allowed differentiation of the non-pregnant cases from the normal intrauterine pregnancies and the ectopic cases, but not ata all between the different forms of intrauterine early pregnancy failures and ectopic pregnancies. By ultrasound, however, it was possible to reliably diagnose intrauterine pregnancies from the 7th wk of amenorrhea onwards, and to classify them into the normal and pathological subgroups. The direct demonstration of ectopic pregnancy by ultrasound is problematic, but the exclusion of intrauterine pregnancy by this method, combined with the simultaneous plasma hCG determination by sensitive and rapid method, can be recommended for primary examinations in suspected ectopic pregnancy.

Abortion, Incomplete↗
PubMed1992

The history of the diagnosis and treatment of ectopic pregnancy: a medical adventure.

From its indirect reference by Abulcasis (936-1013) and until the 19th century the ectopic pregnancy was known as a universally fatal accident. By reporting successful treatment of tubal pregnancy with salpingectomy in 1884 Robert Lawson Tait (1845-1899) started an era of almost 70 years of exclusively extirpative treatment of ectopic pregnancy. The technologic revolution of the 20th century improved diagnostic capabilities so that diagnosis of unruptured ectopic pregnancy becomes feasible and even mandatory. Side by side our understanding of the natural history of ectopic pregnancy improved. Many patients with early-resolving ectopic pregnancies escape surgical treatment. Preservation of future fertility became possible with the introduction of conservative surgical procedures and with the use of methotrexate. The main achievement in the treatment of ectopic pregnancy over the past 110 years is the dramatic decrease in mortality rate: from 72-90% in 1880 to 0.14% in 1990.

Female↗
PubMed1995

Primary application of three-dimensional ultrasonography to early diagnosis of ectopic pregnancy.

OBJECTIVE: Preliminary evaluation of three-dimensional (3D) imaging for early diagnosis of ectopic pregnancy. STUDY DESIGN: Twelve asymptomatic patients before six weeks of amenorrhea and with no feature of intrauterine nor of ectopic pregnancy at traditional bidimensional ultrasonography were considered. Laparoscopy showed ectopic pregnancy in 9 cases. RESULTS: 3D transvaginal ultrasonography preceding laparoscopy showed small ectopic gestational sac in 4 cases. Moreover the fallopian tube on the side of ectopic pregnancy could be imaged in all cases. This was possible because the fallopian tube was surrounded by a fine hypoechogenic border, an apparently specific feature which had not been reported previously. CONCLUSION: These preliminary data suggest that 3D ultrasonography is an effective procedure for early diagnosis of ectopic pregnancy in asymptomatic patients before six weeks of amenorrhea.

Fallopian Tubes↗
PubMed1984

Detection of ectopic pregnancy in an outpatient population: the role of the beta-HCG level.

A retrospective analysis was made of 265 female outpatients who initially presented to an emergency department with a complaint of amenorrhea, vaginal bleeding, or abdominal/pelvic pain. The patients were discharged from the emergency department pending results of a serum pregnancy test. Forty-five of the patients were subsequently found to have an elevated (greater than 5 mIU/mL) beta human chorionic gonadotropin (HCG) level. Six of the patients had an ectopic pregnancy; their beta HCG levels ranged from 19 to 265 mIU/mL. A detectable beta HCG level less than 500 mIU/mL had a 33% probability of an ectopic pregnancy in the study group. Historical features, physical examination, and laboratory parameters were of limited value for identification of minimally symptomatic outpatients at risk for an ectopic pregnancy. No study patient had a systolic blood pressure of less than 86 mm Hg on presentation. A comparison group of 29 patients admitted to the hospital directly from the emergency department with a diagnosis of "rule out ectopic pregnancy" during the same time interval was identified. Nine of the directly admitted patients were found to have ectopic pregnancies. A statistically greater proportion of the directly admitted patients had a hematocrit less than 35% and a positive urine (tube) pregnancy test than that found for the study group. Five of the comparison group patients were noted to have a systolic blood pressure of less than or equal to 80 mm Hg. The beta HCG was found to be an essential tool in the evaluation of potential ectopic pregnancy in patients with minimal symptomatology.

Adult↗
PubMed2004

HOXA10 gene expression in human fallopian tube and ectopic pregnancy.

OBJECTIVE: The molecular mechanisms underlying ectopic implantation have not been well characterized. Here we investigate HOXA10 gene expression at the site of ectopic implantation as compared with the endometrium and with the normal fallopian tube. STUDY DESIGN: Northern blot analysis was used to evaluate HOXA10 gene messenger RNA level in various segments of normal pregnant and nonpregnant human fallopian tube, ectopic pregnancy, and endometrium. RESULTS: Normal human fallopian tube expressed minimal levels of HOXA10 gene messenger RNA in the nonpregnant state. A trend toward a greater expression of HOXA10 gene was observed in the normal fallopian tube during pregnancy, but the difference was not statistically significant (P =.075). HOXA10 gene messenger RNA expression was up-regulated significantly at the site of implantation in ectopic pregnancy (P <.001), and its expression approached that of the endometrium during normal pregnancy (P =.33). CONCLUSION: HOXA10 gene expression is up-regulated at the ectopic implantation site in the fallopian tube, approaching that of the endometrium in normal intrauterine gestation. Inherently increased HOXA10 gene expression in the fallopian tube or dysregulation of HOXA10 gene expression by an abnormally implanting blastocyst may play a role in ectopic implantation.

Blotting, Northern↗
PubMed2004

Maternal life events and adverse pregnancy outcomes: lessons from the Auvergne ectopic pregnancy registry.

OBJECTIVE: To investigate stressful maternal life events as candidate risk factors for ectopic pregnancy. DESIGN: Population-based registry study. SETTING: Auvergne ectopic pregnancy registry (France). PATIENT(S): Women (n = 641) registered between 1997 and 2000. INTERVENTION(S): Standard treatment of ectopic pregnancy. MAIN OUTCOME MEASURE(S): Based on the Psychiatric Epidemiology Life Events Scale, we analyzed the nonresponse bias, the confounding effects of sociobehavioral factors associated with both life events and ectopic pregnancy, and the potential buffering effects of socio-cultural variables. A multivariate model was constructed to test the association between life events and ectopic pregnancy, adjusting for identified confounders and testing interactions. RESULT(S): The primary hypothesis that life events might be independent risk factors for ectopic pregnancy was not confirmed in this study, which nevertheless illustrated the numerous biases and measurement problems confronting association studies of life events with adverse pregnancy outcomes. CONCLUSION(S): Recommendations are made for future studies on life events and adverse pregnancy outcomes to avoid most selection, information, and confounding biases. Methodological improvements are needed for measurement of life events to develop measures that more closely consider the consequences of stress and the mechanisms of buffering.

Adult↗
PubMed2004

Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound-guided aspiration and single-dose methotrexate.

OBJECTIVE: To present a case of cervical ectopic pregnancy successfully treated with ultrasound-guided aspiration and single-dose methotrexate administered systemically. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old nulliparous woman with a cervical ectopic pregnancy. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical ectopic pregnancy followed by single-dose methotrexate administered systemically. MAIN OUTCOME MEASURE(S): Recovery of the patient, successful conservative treatment of the cervical ectopic pregnancy, with preservation of the uterus. RESULT(S): The cervical ectopic pregnancy was successfully aborted, and the reproductive capability of the patient was preserved. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with single-dose methotrexate administered systemically can be safely used to treat cervical ectopic pregnancies.

Abortifacient Agents, Nonsteroidal↗
PubMed2004

Characterizing ectopic pregnancies that rupture despite treatment with methotrexate.

OBJECTIVE: To identify risk factors for tubal rupture among ectopic pregnancies treated with methotrexate (MTX). DESIGN: Retrospective case-control analysis. SETTING: An urban medical center. PATIENT(S): Eighty-one women diagnosed with an ectopic gestation treated with MTX: 19 patients experienced subsequent tubal rupture, and 62 patients experienced ectopic resolution. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Predictive variables including serial human chorionic gonadotropin (hCG) values. RESULT(S): The hCG incremental rate before as well as after MTX administration was positively associated with tubal rupture. HCG values prior to ectopic diagnosis that increased at least 66% over 48 hours and rising hCG values after treatment with methotrexate were independent predictors of tubal rupture. A disproportionate number (47%) of ectopic pregnancies that ruptured were located in the tubal isthmus. CONCLUSION(S): The hCG incremental rate both before and after MTX represents an independent risk factor for subsequent tubal rupture. Concentrations of hCG before ectopic diagnosis that increased at least 66% over 48 hours, or persistently rising hCG concentrations after treatment with MTX, may lower the threshold for surgical intervention. Implantation site may represent an unidentifiable risk factor for tubal rupture.

Abortifacient Agents, Nonsteroidal↗