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PubMed1999

Implementation of probabilistic decision rules improves the predictive values of algorithms in the diagnostic management of ectopic pregnancy.

Current algorithms for the diagnosis of ectopic pregnancy do not take into account the heterogeneity in patient profiles. Such heterogeneity can lead to differences in the pre-test probability of ectopic pregnancy. In patients with clinical symptoms, for example, the probability of presence of an ectopic pregnancy is higher than in symptom-free patients. Any additional tests should then be interpreted differently, depending on the pre-test probability. We present a diagnostic algorithm that uses probabilistic decision rules for the evaluation of women with suspected ectopic pregnancy with flexible cut-off levels for test positivity We compare it with a general algorithm that uses fixed cut-off levels. Fictitious cohorts, varying in prevalence of ectopic pregnancy were put together, using data obtained from a cohort of >800 women with suspected ectopic pregnancy. In the inflexible algorithm, ectopic pregnancy was diagnosed whenever it could be visualized at transvaginal sonography, or where serum human chorionic gonadotrophin (HCG) exceeded a rigid cut-off level; ectopic pregnancy was rejected if an intrauterine pregnancy was seen or when serum HCG decreased. In the flexible algorithm, a post-test probability was obtained after each test, using pre-test probabilities and test-based likelihood ratios. Ectopic pregnancy was diagnosed whenever the post-test probability for ectopic pregnancy exceeded 95%, whereas this diagnosis was rejected if the calculated post-test probability fell below 1%. For both algorithms, sensitivity and specificity as well as predictive values were calculated. At each prevalence, the inflexible algorithm was associated with a sensitivity of 93% and a specificity of 97%. In contrast, the sensitivity and specificity of the flexible, individualized algorithm depended on the prevalence of ectopic pregnancy. Consequently, predictive values varied strongly when the inflexible algorithm was used, whereas they were much more stable after using the flexible algorithm. For five possible valuations of false positive and false negative diagnoses, the flexible algorithm reduced the expected disutility, compared with the inflexible algorithm. It is concluded that clinicians should incorporate probabilistic decision rules in algorithms used for the diagnosis of ectopic pregnancy.

Algorithms↗
PubMed2002

Evaluation of serum creatine kinase in ectopic pregnancy with reference to tubal status and histopathology.

OBJECTIVE: To study the value of creatine kinase in ectopic pregnancy with reference to tubal histopathology. DESIGN: Prospective controlled study. SETTING: Academic tertiary-care institution. POPULATION: Thirty-two women with ectopic pregnancy and 20 controls with intrauterine pregnancies. METHODS: Creatine kinase and beta-hCG levels were measured on admission. Ectopic pregnancies were removed at surgery and examined histologically. MAIN OUTCOME MEASURES: Tubal localisation and integrity of ectopic pregnancies as judged at surgery and later histologically, and placental growth patterns in unruptured ectopic pregnancies classified as intraluminal, extraluminal or mixed as determined histologically. RESULTS: Creatine kinase levels were higher in isthmic than ampullary ectopic pregnancies (P = 0.011), and higher in ruptured than in unruptured cases (P = 0.003) and normal pregnancies (P < 0.0001). A creatine kinase value >120iu/L was 65% sensitive and 87% specific in discriminating ruptured from unruptured ectopic pregnancies. Creatine kinase levels were above this cutoff in two of five unruptured ampullary ectopic pregnancies with invasive trophoblastic growth, yet in none of nine cases with intraluminally confined placentation (P = 0.04). Creatine kinase was positively correlated with gestational age in ruptured (P = 0.007), but not in unruptured ectopic pregnancies or normal pregnancies. CONCLUSIONS: Serum creatine kinase may help in discriminating ruptured from unruptured ectopic pregnancies, while it is not useful for the primary diagnosis of ectopic pregnancy. An increase in creatine kinase levels accompanying muscular damage in ectopic pregnancy probably antedates tubal rupture, and may be related to trophoblastic growth patterns.

Adult↗
PubMedDate not supplied

Occurrence of ectopic pregnancy among women with recurrent spontaneous abortion.

Ectopic pregnancy is a major health problem accounting for about 10% of all maternal mortality. To determine whether patients with a history of recurrent spontaneous abortion (RSA) have a higher frequency of ectopic pregnancy than the general population, the obstetrical histories of 630 patients with a diagnosis of RSA from two centers were studied. Thirty-eight of 376 USA women, (10%) and 10 of 193 British women (5%) previously had suffered an ectopic pregnancy. These data provide an overall prevalence of 9% for ectopic pregnancy among patients who recurrently abort. The total number of pregnancies was 1,716 in the USA group and in the British group was 1,270, for a total of 2,986 including live births, stillbirths, abortions, hydatidiform moles, and ectopic pregnancies. In the US series, 45 of the 1,716 pregnancies were ectopic. If these women had the same relative proportion of ectopic pregnancies as the general population, there should have been 20.6 ectopic pregnancies. This represents a 2.2-fold increase in patients with a history of RSA. There was no association between pregnancy order and occurrence of ectopic pregnancy. The prevalence of known risk factors for ectopic pregnancy in patients with a history of ectopic pregnancy was PID, 3%; tubal surgery, 20%; and used IUD, 3%. Seventy-four percent of the women had no identifiable risk factor. These results suggest a comorbidity for ectopic pregnancy and RSA which may indicate shared etiologies.

Abortion, Habitual↗
PubMed2000

Factors influencing reproductive performance following previous ectopic pregnancy.

OBJECTIVE: To assess the factors that influence the reproductive performance in patients who had previous salpingectomy by laparotomy for ectopic pregnancy in the South-west Region of Saudi Arabia. METHODS: Fifty four patients who had pregnancies following salpingectomy for previous ectopic pregnancy were studied retrospectively at Abha Maternity Hospital in the Southern Region of Saudi Arabia. RESULTS: There were 130 ectopic pregnancies during the study period out of which 54 patients became pregnant subsequently. Of the subsequent pregnancies, there were 41 (80%) intrauterine pregnancies and 13 (20%) extrauterine recorded pregnancies. Out of the intrauterine pregnancies, 36 (88%) resulted in full term live births while abortion occurred in 5 (12%) of the cases. The risk of a 2nd ectopic pregnancy seemed to be positively related to the age of the patient and also the interval between the previous ectopic and new pregnancy, while it was negatively related to the parity of the patient. The mean age of the patients was 27.89 years and the mean parity 2.74. Of the 13 patients who had extrauterine pregnancies, 4 (30%) were nulliparous while 9 (70%) had had between 1-5 children. In those patients who had a repeat ectopic pregnancy, the mean gestation of the ectopic pregnancy was 6.78 weeks while the interval between admission to hospital and surgery ranged between 1 to 48 hours with a mean of 21.85 hours. At the time of surgery, the fallopian tube was ruptured in 6 (46%) of the cases and these included patients who were nulliparous. They all had repeat salpingectomy. Conservative surgery was performed only in 2 (28%) of those whose fallopian tubes were not ruptured at the time of surgery. CONCLUSION: It seemed as if the probability of repeat ectopic pregnancy increased as the age of the patient increased and the interval between the previous ectopic gestation and new pregnancy is prolonged. At the same time the probability of another ectopic pregnancy decreased as the parity increased. The obstetric outlook following laparotomy for ectopic pregnancy seemed not to be very encouraging as the fertility rate was about 48% and therefore, efforts should be geared at managing patients with ectopic pregnancy laparoscopically. A larger multicenter study is needed to validate these findings.

Adolescent↗
PubMed2002

[Fertility after ectopic pregnancy at the University Hospital in Dakar].

The aims is to evaluate fertility and medical cost about post ectopic pregnancy follow up. It is about a retrospective and descriptive study about 337 patients who have the opportunity to get a salpingectomy for an ectopic pregnancy between 1989 and 1997 at Le Dantec Gynecological and Obstetrical Clinic. After the ectopic pregnancy cure, women are followed with contraception, just time before trying to obtain another pregnancy. The studied parameters are: age, parity, socio-economical status, level of instruction, obstetrical and gynecological antecedents, Chlamydia serology, hysterosaipingography data, fertility after ectopic pregnancy, fees related to the cost of follow up after ectopic pregnancy. Data exploitation is done through an epidemiologic programme named Epi Info version 5 The average age of the patients was 27 years and that of the parity was 2.70. 87.83% of women were married. More than the half of those patients came from the suburb of Dakar. 171 patients (50.74%) were followed regularly, the other 166 (49.26%) disappeared. A Chlamydia trachomatis infection was found among 23.4% of cases. A tubal obstruction was noted in the level of the horns at 12.5 % of women. No case of maternal death was observed. Among 59 patients who wished a pregnancy, 34 ectopic pregnancy had been obtained (57.62%) in 4 month after stopping contraception and 26 cases of a new ectopic pregnancy. The expenses of medical cure after ectopic pregnancy are about 17.814 to 71,574.65 F CFA with an average of 38,689 F CFA (389.89 FF). Medical care after ectopic pregnancy raises a lot of problems: --some patients disappeared probably because of the inaccessibility of financial cost, --the high rate of Chlamydial trachomatis infection, an hypofertility after ectopic pregnancy. To combat this, we have to insist in the prevention of sexually transmitted diseases in general and of the chlamydial infection in particular. We have also to insist in the early diagnosis of the ectopic pregnancy. At last, we must set up a registre of ectopic pregnancy at the national level.

Adolescent↗
PubMed1996

[Treatment of ectopic pregnancies by laparotomy in under-equipped countries. A series of 144 cases at the Yaounde University Hospital Center (Cameroon)].

We report in the context of a developing country the results of ectopic pregnancies treated by laparotomy in the last ten years (1984-1993) in the maternity unit of the Teaching Hospital Yaounde (Cameroons). There were 144 cases of ectopic pregnancies from a total of 12,507 deliveries; this corresponds to 11 cases of ectopic pregnancies for 1,000 deliveries. In 75 cases (52%) the patients were operated in emergency situations with clinical signs of ruptured ectopic pregnancy which were later confirmed at laparotomy. In 69 cases (47.9%) the patients were retained in hospital for definitive diagnosis and in the follow-up, the diagnosis was confirmed by laparoscopy in 37 cases (53.6%) and by ultrasonography in 22 cases (31.9%). In this study the frequency of ectopic pregnancy was most common among primiparous women (36 cases) and second parity (37 cases). The highest frequency of ectopic pregnancies was found in women in the age range between 25 and 30 years. Radical treatment of ectopic pregnancy was performed in 62 cases (43.0%) and conservative treatment in 82 cases (56.9%). The main complication during the operation was represented by severe hemorrhage in 65 cases (45.1%); blood transfusion was required in 25 cases. Among the patients who were followed up in the prenatal clinic (98 cases) 16 patients (16.3%) presented an intra-uterine pregnancy and 12 patients (12.2%) a recurrence of ectopic pregnancy. Ectopic pregnancy is a frequent pathology in Cameroon. In the absence of methods for early diagnosis of ectopic pregnancy such as endovaginal ultrasonography and the measurement of beta human chorionic gonadotropin (beta hCG), primary use of laparotomy is necessary when clinical signs of ectopic pregnancy exist. This procedure permits the avoidance of severe complications such as hemorrhage and maternal death. It can be said that laparotomy still has its place in the treatment of ectopic pregnancy in developing countries.

Adolescent↗
PubMed1997

[Relationship between microsurgical tubal reversal and ectopic pregnancy].

OBJECTIVE: To study the correlation between microsurgical tubal reversal after tubal sterilization and ectopic pregnancy. METHODS: 1029 women who underwent microsurgical tubal reversal were followed up. The causes of ectopic pregnancy were analysed and discussed. RESULTS: 960 intrauterine pregnanciess and 12 ectopic pregnancies occurred. The 12 ectopic pregnancies were all tubal ones, among which 2 had intrauterine pregnancies. The rate of ectopic pregnancy in the 1029 women was 1.17%, and in the pregnant cases was 1.23%. The ratio of intrauterine pregnancy to ectopic pregnancy was 1:80. The rates of ectopic pregnancy in the 1st, 2nd year and 2 years later after tubal reversal were not significantly different respectively among the tubal reversal and among the pregnant cases. The rates of ectopic pregnancy in the 1st and 2nd 6 months after tubal reversal were not statistically different. The early tubal hydrapertubation could only increase the chance of ectopic pregnancy. The sterilization method, reversal mode, and interval between sterilization and reversal were not related to the ectopic pegnancy. CONCLUSION: When the lesion in the sterilized position is completely removed, the sutures being through the tubal mucosa and the early tubal hydrapertubation not carried out, the chance of ectopic pregnancy can not be increased after tubal reversal. The contraception 6 months after tubal reversal is not related to ectopic pregnancy.

Adult↗
PubMed2005

Predictors of non-pulmonary vein ectopic beats initiating paroxysmal atrial fibrillation: implication for catheter ablation.

OBJECTIVES: The purpose of this study was to investigate the predictor of non-pulmonary vein (PV) ectopic beats initiating paroxysmal atrial fibrillation (PAF). BACKGROUND: Non-PV ectopic beats can initiate PAF in some patients and play an important role in the recurrence of PAF after PV isolation. Information on the predictors of non-PV ectopic beats initiating PAF is unknown. METHODS: This study included 293 patients (215 men and 78 women, age 60 +/- 14 years) with clinically documented drug-refractory PAF. Of the 94 patients with non-PV ectopic beats initiating PAF, 38 (40%) patients had superior vena cava (SVC) ectopic beats and 32 (34%) had left atrial posterior free wall (LAPFW) ectopic beats. RESULTS: In a univariate analysis, only female gender was related to the presence of non-PV (p = 0.016) and SVC ectopic beats (p = 0.012). Right atrial enlargement (p = 0.005) and left atrial enlargement (p < 0.001) were related to the presence of LAPFW ectopic beats. In a multivariate analysis, female gender (p = 0.043; odds ratio 2.00, 95% confidence interval [CI] 1.02 to 3.92) and left atrial enlargement (p = 0.007; odds ratio 2.34, 95% CI 1.27 to 4.32) could predict the presence of non-PV ectopic beats. Subgroup analysis showed that female gender could predict the presence of SVC ectopic beats (p = 0.039; odds ratio 2.14, 95% CI 1.04 to 4.43). In contrast, left atrial enlargement could predict the presence of LAPFW ectopic beats (p = 0.002; odds ratio 3.89, 95% CI 1.62 to 9.38). CONCLUSIONS: The location of non-PV ectopic beats initiating PAF can be predicted by both gender and left atrial enlargement.

Atrial Fibrillation↗
PubMed2000

Ultrasound availability in the evaluation of ectopic pregnancy in the ED: comparison of quality and cost-effectiveness with different approaches.

The liberal use of ultrasonography has been advocated in patients with first trimester cramping or bleeding to avoid misdiagnosis of ectopic pregnancy in the emergency department (ED). The cost-effectiveness of different approaches to ultrasound availability has not been previously reported. In this study, we investigated measures of quality and cost-effectiveness in detecting ectopic pregnancy in the ED over a 6-year period, divided into three approximately equal epochs with three distinct approaches to ultrasound availability. The study retrospectively identified 120 cases of ectopic pregnancy seen in the ED over 6 years. There was significant improvement in the percentage of patients with ectopic pregnancy who were documented to have absence of intrauterine pregnancy (IUP) at the first visit from 76% during Epoch 1, when there was limited availability of ultrasound through medical imaging (MI Sono), to 88% in Epoch 2, when MI Sono was readily available, to 96% in Epoch 3, when both MI Sono and ultrasound by emergency physicians (ED Sono) were readily available (P = .02). The estimated number of MI Sonos ordered by emergency physicians in patients at risk for ectopic pregnancy increased from 5.2 per ectopic pregnancy in Epoch 1 to 11.8 per ectopic pregnancy in Epoch 2, and declined to 5.5 per ectopic pregnancy in Epoch 3, when 19.9 ED Sonos per ectopic pregnancy were also done. The cost of ED Sono in Epoch 3 was more than offset by savings from avoiding calling in ultrasound technicians after regular medical imaging department hours. The specificity of ED Sono in ruling in an IUP was 100% (95% CI 98.3 to 100%), but analysis of secondary quality indicators reflecting times from first ED visit to treatment in Epoch 3 raised the possibility that an adnexal mass or signs of tubal rupture may have been missed on some ED Sonos. We conclude that increased availability of ultrasonography leads to improved quality in the detection of ectopic pregnancy in the ED, but at the expense of a disproportionate increase in the number of ultrasound studies done per ectopic pregnancy detected. Our study suggests that the most cost-effective strategy is for emergency physicians to screen all patients with first trimester cramping and bleeding with ED Sonos, and to obtain MI Sonos at the time of the initial ED visit in all cases in which the ED Sono is indeterminate or shows no IUP.

Adult↗
PubMed1998

Screening for chlamydial infections and the risk of ectopic pregnancy in a county in Sweden: ecological analysis.

OBJECTIVES: To analyse trends in rates of genital chlamydial infection and ectopic pregnancy between 1985 and 1995 in a county in Sweden. SETTING: Uppsala county where screening for chlamydial infection, treatment, and contact tracing has been widespread and where ectopic pregnancies are recorded. METHODS: Rates of chlamydial infections and ectopic pregnancy between 1985 and 1995 were calculated for women aged 20-39 years. Poisson and linear regression were used to examine the association between the risk of ectopic pregnancy and the current rates of chlamydial infection and rates of chlamydial infection from up to 5 years earlier. MAIN OUTCOME MEASURES: Rates of chlamydial infection per 100 examinations, rates of ectopic pregnancy per 1000 pregnancies, rate ratios and 95% confidence intervals for an increase in chlamydial infections of 5 new cases per 100 examinations. RESULTS: 103 870 cervical samples from women aged 15-39 years were analysed; 5648 (5.4%) were positive for chlamydia. 51 630 pregnancies were analysed; 930 (1.8%) were ectopic. Both rates declined over time. For women aged 20-24 years there was a strong correlation between the rate of ectopic pregnancy and the rate of chlamydial infection in the same year (r=0.93, P<0. 001); among older women correlations were stronger with rates of chlamydial infection occurring 1 or 2 years earlier. In Poisson regression ectopic pregnancy was most strongly associated with the current rate of chlamydial infection among women aged 20-24 (rate ratio 1.85, 95% confidence interval 1.44 to 2.38), with the rate of infection 1 year earlier among 25-29 year olds (rate ratio 1.72, 1. 33 to 2.22) and 30-34 year olds (rate ratio 2.27, 1.53 to 3.37); and with the rate 2 years earlier among 35 to 39 year olds (rate ratio 2. 58, 1.45 to 4.60). CONCLUSIONS: Declining rates of genital chlamydial infections have probably led to a fall in the rate of ectopic pregnancies. The timing of the decline in the rate of ectopic pregnancies varies with age. Among young women falling rates of chlamydial infection have been accompanied by an immediate reduction in the rate of ectopic pregnancy.

Adolescent↗
PubMed1997

Increasing incidence of ectopic pregnancy in one Norwegian county--a population based study, 1970-1993.

OBJECTIVE: To estimate time trends related to ectopic pregnancy while considering the contribution of repeat ectopic pregnancy and changing treatment for infertile couples over the past 24 years. METHODS: Population based incidence data on ectopic pregnancy were collected from the only two hospitals in one Norwegian county from 1970 through 1993. Cases were identified through hospital discharge registries and all medical records were reviewed. Only females, aged 15-44 years, living permanently in the county and having a histologically verified ectopic pregnancy were eligible for the study. Data were analyzed in 5-year periods and 5-year age-groups. RESULTS: The incidence of ectopic pregnancy (per 1,000 woman-years) increased fourfold from the first to the last period. When we restricted the analyses to women with no previous ectopic pregnancy and no previous infertility surgery or treatment, we observed a linear threefold increase in the number of ectopic pregnancies. CONCLUSIONS: Repeat ectopic pregnancy and increased infertility treatment in the late 1970s and early 1980s might explain at most 25% of the increase in the incidence of ectopic pregnancy. After 1985, assisted reproduction might contribute to 4-5% of ectopic pregnancies diagnosed. The introduction of laparoscopy might explain some of this increase in the 1970s; however, we doubt that the introduction of more sensitive pregnancy tests or vaginal ultrasound in the 1980s contributed to the observed increase in ectopic pregnancy.

Adolescent↗
PubMed2004

Sonographically guided minimally invasive treatment of unusual ectopic pregnancies.

OBJECTIVE: To present our experience with sonographically guided treatment of unusual ectopic pregnancies, defined as heterotopic pregnancies and pregnancies occurring at ectopic locations other than the extracornual portion of the fallopian tube. METHODS: We retrieved and reviewed all cases of unusual ectopic pregnancies that underwent sonographically guided therapy at our institution. Twenty-seven cases were identified, from 1992 through 2003, including 18 cervical, 6 cornual, 1 tubal heterotopic, and 2 cesarean scar implantations. RESULTS: All of the cervical ectopic, cornual ectopic, and tubal heterotopic pregnancies were treated by sonographically guided injection of potassium chloride into the ectopic gestational sac or fetus. Guidance was via transvaginal sonography in all 18 cervical pregnancies, 3 of the 6 cornual pregnancies, and the tubal heterotopic pregnancy, and via transabdominal sonography in 3 cornual ectopic pregnancies. One of the cesarean scar pregnancies was treated by transvaginally guided potassium chloride injection, and the other was treated via transabdominally guided dilation and evacuation. Treatment was successful in 25 of the 27 patients, including all 23 patients with an ectopic pregnancy and no concomitant intrauterine pregnancy. Four patients had concomitant intrauterine and ectopic pregnancies (1 cervical, 2 cornual, and 1 tubal); in 3 the intrauterine fetuses resulted in live-born infants, and in the fourth the intrauterine pregnancy was electively terminated. Eight of the 27 patients had subsequent intrauterine pregnancies. CONCLUSIONS: Sonographically guided minimally invasive treatments of unusual ectopic pregnancies are safe and effective alternatives to surgical and systemic medical therapy. These treatments ablate the ectopic pregnancy, permit normal continuation of a concomitant intrauterine pregnancy, and preserve the uterus for subsequent pregnancies.

Adult↗
PubMed1990

[Clinical study of ectopic eruption of the permanent first molars].

The purpose of this study was to investigate the etiology and characteristics of the ectopic eruption of first permanent molars. The subjects were 35 cases (27 maxilla and 8 mandible) with ectopically erupted permanent first molars, which were recognized in 24 out-patients (10 boys and 14 girls) visiting Tohoku University, Dental Hospital. The materials used for the analysis were dental casts, X-ray lateral cephalograms and panoramic radiographs, and both materials of the ectopic and normal groups were compared. The results were as follows: 1) There were no significant differences statistically between the mesio-distal crown diameters of the maxillary permanent first molar, central and lateral incisor, and all deciduous teeth in ectopic group and their mean values in Ono's and Otsubo's studies. 2) There were no significant differences as compared to all parts of the size of the dental arch in ectopic sides with those in the normal sides of same individuals at IIA and IIC of Hellman's developmental stage in dentition. 3) When the sizes of the dental arch in the ectopic group were compared with those of the normal group, the former were smaller at the distance between the mid-point and the canine mesial surface (Fig. 1-4), the ridge of the posterior region of the basal arch and most distal point of the primary second molar (Fig. 1-6) at the Hellman's dental age IIA, while the canine distance to the midline (Fig. 1-1), the dental arch perimeter from mid-point to the distal surface of primary second molar (Fig. 1-4+5), and the distance between the canine and primary second molar, div. X (Fig. 1-7) at Hellman's dental age of IIC were significantly smaller than the latter. 4) Regarding the comparison of the value of the changes in dental arch size between the ectopic group and the normal group from Hellman's dental age of IIA to IIC, the distance between the canine and primary second molar, div. X (Fig. 1-7) decreased markedly and the distance between the ridge of the posterior region of the basal arch and the most distal point of the primary second molar (Fig. 1-6) increased. 5) Results of the analysis of X-ray lateral cephalograms showed that the angle of eruption of first molars in the ectopic group was significantly smaller compared with normal group. 6) According to the cluster analysis on the calcification of tooth germ using panoramic radiographs, similarity among all of the samples was lacking in the ectopic group, especially congenital missing of the second molars and second premolars in the ectopic side and the delayed calcification of the ectopically erupted teeth were found in maxilla.

Child↗
PubMed1981

Contemporary management of ectopic pregnancy.

Over the five years 1975-79 at Yale-New Haven Hospital, ectopic pregnancy changed from a disease requiring acute emergency are utilizing radical surgery for a ruptured ectopic to a disease requiring chronic, observant care utilizing conservative treatment for the unruptured ectopic. One hundred ninety-five cases of ectopic pregnancy have been retrospectively reviewed to determine how laparoscopy, ultrasound and beta pregnancy testing have affected this change. Over the reviewed period of time, the rate of diagnosed and treated unruptured ectopic pregnancies increased from 8% to 35%. Those patients with ectopic pregnancies having laparoscopy prior to laparotomy rose from 11% to 29.5%. Ultrasound diagnosed intrauterine pregnancy in 13% of those patients suspected of having an ectopic pregnancy by defining an intrauterine gestational sac and demonstrated a mass in 85% of patients diagnosed as having an ectopic pregnancy, although the mass was not always the ectopic pregnancy. Beta pregnancy testing, available only over the past two years, was positive in 99%, with only one false negative. One hundred twenty-eight culdocenteses were done, with 85% positive, and was the most important factor in deciding on emergency versus expectant care. These factors have allowed us to treat ectopic pregnancy expectantly, making the diagnosis sooner and more accurately, leading to an increase in conservative treatment and employing salpingostomy as opposed to salpingectomy as the rate of unruptured ectopic pregnancy increases.

Female↗
PubMed1992

Ectopic expression of UBX and ABD-B proteins during Drosophila embryogenesis: competition, not a functional hierarchy, explains phenotypic suppression.

The Abdominal-B (Abd-B) gene, a member of the bithorax complex (BX-C), specifies the identities of parasegments (PS) 10-14 in Drosophila. Abd-B codes for two structurally related homeodomain proteins, ABD-B m and ABD-B r, that are expressed in PS10-13 and PS14-15, respectively. Although ABD-B m and r proteins have distinct developmental functions, ectopic expression of either protein during embryogenesis induces the development of filzkörper and associated spiracular hairs, structures normally located in PS13, at ectopic sites in the larval thorax and abdomen. These results suggest that other parasegmental differences contribute to the phenotype specified by ABD-B r activity in PS14. Both ABD-B m and r repress the expression of other homeotic genes, such as Ubx and abd-A, in PS10-14. However, the importance of these and other cross-regulatory interactions among homeotic genes has been questioned. Since ectopic UBX protein apparently failed to transform abdominal segments, González-Reyes et al. (González-Reyes, A., Urquía, N., Gehring, W.J., Struhl, G. and Morata, G. (1990). Nature 344, 78-80) proposed a functional hierarchy in which ABD-A and ABD-B activities override UBX activity. We tested this model by expressing UBX and ABD-B m proteins ectopically in wild-type and BX-C-deficient embryos. Ectopic ABD-B m does not prevent transformations induced by ectopic UBX. Instead, ectopic UBX and ABD-B m proteins compete for the specification of segmental identities in a dose-dependent fashion. Our results support a quantitative competition among the homeotic proteins rather than the existence of a strict functional hierarchy. Therefore, we suggest that cross-regulatory interactions are not irrelevant but are important for repressing the expression of competing homeotic proteins. To explain the apparent failure of ectopic UBX to transform the abdominal segments, we expressed UBX at different times during embryonic development. Our results show that ectopic UBX affects abdominal cuticular identities if expressed during early stages of embryogenesis. In later embryonic stages, abdominal segments become resistant to transformation by ectopic UBX while thoracic segments remain susceptible. Head segments also show a similar stage-dependent susceptibility to transformation by ectopic UBX in early embryogenesis but become resistant in later stages. These results suggest that abdominal and head identities are determined earlier than are thoracic identities.

Animals↗
PubMed1991

Risk factors for ectopic pregnancy: a case-control study in France, with special focus on infectious factors.

A case-control study was conducted in 1988 in seven Paris area maternity hospitals to evaluate the role of several risk factors, particularly infectious factors, in ectopic pregnancy. A total of 279 cases and 279 controls were compared for sociodemographic characteristics, cigarette smoking, sexual, reproductive and surgical histories, and conditions of conception. Pelvic inflammatory disease confirmed by celioscopy (odds ratio (OR) = 5.5, 95% confidence interval (CI) 2.1-13.9) and Chlamydia trachomatis seropositivity (OR = 3.9, 95% CI 2.3-6.7) appeared to be important risk factors for ectopic pregnancy. Other risk factors found to be associated with an increased risk of ectopic pregnancy were dose-related cigarette smoking at the time of conception (ORs 1.3 to 2.5), appendectomy (OR = 1.6, 95% CI 1.1-2.5), prior tubal surgery (OR = 5.1, 95% CI 1.7-15.4), induced conception cycle (OR = 3.2, 95% CI 1.1-9.3), and prior ectopic pregnancy (OR = 13.3, 95% CI 4.5-39.2). However, some of the latter risk factors, i.e., prior tubal surgery, prior ectopic pregnancy, and perhaps appendectomy, may be considered to be the results of pelvic inflammatory disease and sexually transmitted diseases. Maternal age, parity, prior induced abortion, and prior spontaneous abortion were not associated with ectopic pregnancy. Use of intrauterine device, progestagen micropill, and also combined estroprogestative pill at the time of conception were associated with a better prevention of intrauterine pregnancy than of ectopic pregnancy. These findings confirm the importance of several previously reported risk factors of ectopic pregnancy: sexually transmitted diseases, cigarette smoking, and prior ectopic pregnancy. They also identified new risk factors, appendectomy and induced conception cycle, and revealed that the combined estroprogestative pill does not prevent ectopic pregnancy as effectively as it does intrauterine pregnancy.

Adolescent↗
PubMedDate not supplied

Endometrial color flow/image-directed Doppler imaging: negative predictive value for excluding ectopic pregnancy.

PURPOSE: Visualization of an intrauterine pregnancy with transvaginal ultrasound virtually excludes an ectopic pregnancy. However, findings that might lower patients' risk for ectopic pregnancy have not been extensively investigated. We prospectively performed transvaginal color flow/image-directed Doppler imaging of the endometrium to determine the predictive value of endometrial blood flow for excluding ectopic pregnancy. MATERIALS AND METHODS: From April 1994 to August 1995, 211 consecutive women underwent transvaginal ultrasound examination to exclude an ectopic pregnancy. Color flow/image-directed Doppler imaging of the endometrium was performed on each patient. Flow was considered to be present only if a Doppler signal could be obtained with the cursor located completely within the endometrium. All Doppler imaging parameters were optimized for each patient. Resistive indices were obtained if arterial signal was present, and receiver operator characteristic curves were constructed for RI and peak systolic velocity. Findings were correlated with surgical and pathology results. RESULTS: Of 211 total patients, there were 55 ectopic pregnancies (52 diagnosed for a sensitivity of 95%), 89 incomplete spontaneous abortions, 40 completed spontaneous abortions, and 27 intrauterine pregnancies. Of 55 ectopic pregnancies diagnosed with real time imaging, 9 had areas of endometrial blood flow (6 venous, 3 arterial), and 46 did not. Of the 156 patients that did not have an ectopic pregnancy, 107 had arterial blood flow within the endometrium, and 49 had no flow. Using only cases with arterial signal, the negative predictive value of endometrial blood flow for excluding an ectopic pregnancy was 97% (107/107 + 3). The optimal cutoff values (5% false-positive rate) for peak systolic velocity and refractive index (RI) were 15 cm/s and 0.55. CONCLUSIONS: Arterial blood flow within the endometrium lowers the risk for ectopic pregnancy even when other findings that might indicate a high risk are present. Venous flow within the endometrium does not exclude an ectopic pregnancy.

Adolescent↗
PubMed2005

Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location.

OBJECTIVES: Various serum human chorionic gonadotropin (hCG) discriminatory zones are currently used for evaluating the likelihood of an ectopic pregnancy in women classified as having a pregnancy of unknown location (PUL) following a transvaginal ultrasound examination. We evaluated the diagnostic accuracy of discriminatory zones for serum hCG levels of > 1000 IU/L, 1500 IU/L and 2000 IU/L for the detection of ectopic pregnancy in such women. METHODS: This was a prospective observational study of women who were assessed in a specialized transvaginal scanning unit. All women with a PUL had serum hCG measured at presentation. Expectant management of PULs was adopted. These women were followed up with transvaginal ultrasound, monitoring of serum hormone levels and laparoscopy until a final diagnosis was established: a failing PUL, an intrauterine pregnancy (IUP), an ectopic pregnancy or a persisting PUL. The persisting PULs probably represented ectopic pregnancies which had been missed on ultrasound and these were incorporated into the ectopic pregnancy group. Three different discriminatory zones (1000 IU/L, 1500 IU/L and 2000 IU/L) were evaluated for predicting ectopic pregnancy in this PUL population. RESULTS: A total of 5544 consecutive women presented to the early pregnancy unit between 25 June 2001 and 14 April 2003. Of these, 569 (10.3%) women were classified as having a PUL, 42 of which were lost to follow up. Of the 527 (9.5%) cases with PUL analyzed, there were 300 (56.9%) failing PULs, 181 (34.3%) IUPs and 46 (8.7%) ectopic pregnancies. Overall, 74.6% were symptomatic and 25.4% were asymptomatic (P = 8.825E-07). The sensitivity and specificity of an hCG level of > 1000 IU/L to detect ectopic pregnancy were 21.7% (10/46) and 87.3% (420/481), respectively; for an hCG level of > 1500 IU/L these values were 15.2% (7/46) and 93.4% (449/481), respectively, and for an hCG level of > 2000 IU/L they were 10.9% (5/46) and 95.2% (458/481), respectively. CONCLUSIONS: Varying the discriminatory zone does not significantly improve the detection of ectopic pregnancy in a PUL population. A single measurement of serum hCG is not only potentially falsely reassuring but also unhelpful in excluding the presence of an ectopic pregnancy.

Biomarkers↗