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PubMed2002

Isolated fluid in the cul-de-sac: how well does it predict ectopic pregnancy?

We examined the risk of ectopic pregnancy among patients with isolated abnormal cul-de-sac fluid at transvaginal ultrasound. We conducted a retrospective cohort study of all ED patients presenting January 1995 to August 1999 with abdominal pain or vaginal bleeding and a positive beta-hCG test. The risk of ectopic pregnancy in patients with a moderate volume of anechoic fluid was compared with those with either a large volume of anechoic fluid or any echogenic fluid. Ectopic pregnancy was diagnosed in 16/38: 42%(95% CI 26%-59%) of patients with isolated cul-de-sac fluid, 5/23: 22% (95% CI 7%-42%) of patients with moderate amount of anechoic fluid, and 11/15: 73% (95% CI 45%-92%) of patients with a large volume of fluid or any echogenic fluid. These differences were significant (P =.005). Patients with isolated abnormal cul-de-sac fluid are at moderate risk for ectopic pregnancy. The risk increases if the fluid is echogenic or the volume is large.

Ascitic Fluid↗
PubMed1999

Laparoscopic management of ectopic pregnancy.

The incidence of ectopic pregnancy has been rising over the last 20 years. The cause is multifactorial. The technical advancement in the field of minimal access surgery has greatly enhanced the possibility of both diagnosing and treating the condition effectively. The management of ectopic pregnancy can be expectant and surgical; the latter can be by open or laparoscopic methods. Laparoscopic surgery is usually performed when the patient is haemodynamically stable, the hCG is <6000 IU/L, the history is suggestive of minimal pelvic adhesions and when the pregnancy is confined within the tube. This procedure is, however, vastly dependent on the experience and expertise of the surgeon and the equipment facilities available. There are various means of treating ectopic pregnancy by laparoscopy. This includes laparoscopic salpingectomy, salpingotomy, and direct injection of cytotoxic agents. This article will present an overview to ascertain the effectiveness of minimal access surgery in managing ectopic pregnancy. There seems little doubt that laparoscopic management should be the first line of treatment. The way to realize its full potential is by formulating clear guidelines regarding the indication and implementation of laparoscopic surgery and emphasising the role of a fully structured training program to achieve the goals.

Female↗
PubMed1995

[Diagnostic reliability of vaginal ultrasound in ectopic pregnancy].

The therapeutic approach to ectopic pregnancy (EP) has changed over the last decade. A prerequisite for a differentiated management is an early diagnosis of EP. This can be achieved by transvaginal sonography (TVS). The purpose of this study was to evaluate the accuracy of TVS in the diagnosis of EP. 184 patients with clinically suspected ectopic pregnancy were examined by TVS. In 103 cases suspicion of EP was confirmed, in 81 cases it was ruled out. All cases were evaluated by laparoscopy, D&C, serial HCG determinations or sonographic follow-up in case of an intrauterine pregnancy. Sensitivity of TVS in the diagnosis of EP was 96%, specificity 88%, the positive predictive value was 89%, the negative predictive value was 95%. Four cases with a false negative result at TVS were very early in pregnancy and were subjected to laparoscopy because of persistent high HCG values without demonstration of an intrauterine pregnancy. Five cases of sonographically confirmed ectopic pregnancies were missed by the first laparoscopy. These cases required intervention because of clinical symptoms and had low levels of HCG. TVS has a high diagnostic accuracy in the diagnosis of ectopic pregnancy.

Adolescent↗
PubMed1983

[Ectopic pregnancy--significance of serum human chorionic beta gonadotropins and beta-1-glycoprotein (SP1) determination].

In 83 patients with an ectopic pregnancy the serum levels of HCG and the pregnancy specific beta 1 glycoprotein SP-1 were determined. In addition the serum levels of 25 patients with a nonviable pregnancy and 26 non-pregnant patients were determined. The radio-immunologic beta HCG and SP-1 tests and the enzyme immunologic Sp-1 test were used. The radio-immune assay of beta HCG diagnosed 96% of all cases with an ectopic pregnancy. The enzyme and radio-immunologic SP-1 tests failed to diagnose the ectopic pregnancy in 5 of 83 cases (6%) by the Elisa test and in 3 of 83 cases (4%) by the RIA test. The lower limit of diagnosis of pregnancy was considered to be 1.8 micrograms SP-1/1. The concomitant determination of the beta HCG and the SP-1 level permits the diagnosis of ectopic pregnancy in all cases. The main advantage of the enzyme immunologic determination compared to the radio-immunologic determination is at present the materially shorter time factor of the test and the fact that an isotope laboratory is not necessary.

Chorionic Gonadotropin↗
PubMed1982

[Ectopic pregnancy: changes in diagnostic procedures? (author's transl)].

Patients with ectopic pregnancy and those suspected having ectopic pregnancy were reviewed in a twenty years interval (1957-59, 1977-79). These patients were evaluated with regard to medical history, clinical and laboratory findings, diagnostic procedures, and clinical course. The diagnostic usefulness of symptoms and diagnostic procedures is expressed in terms of sensitivity and specificity. According to our results laparoscopy is an ideal procedure for early diagnosis of ectopic pregnancy. Nevertheless, puncture of the Douglas pouch in our experience has its place as a diagnostic tool in the diagnosis of ectopic pregnancy.

Curettage↗
PubMed2002

Oral methotrexate for treatment of ectopic pregnancy.

OBJECTIVE: The purpose of this study was to evaluate oral methotrexate tablets in the treatment of ectopic pregnancy. STUDY DESIGN: Patients with a diagnosis of ectopic pregnancy were offered oral methotrexate tablets rather that intramuscular injection. Oral methotrexate was given in 2 divided doses 2 hours apart at a dose of 60 mg/m(2) with standard 2.5 mg methotrexate tablets. Patients were followed up with the use of the same protocol that was used typically for intramuscular methotrexate. RESULTS: Nineteen of 22 patients (86%) were successfully treated. There was no statistical difference between patients who were treated successfully or unsuccessfully, with respect to initial human chorionic gonadotropin titers (P =.55), ectopic size (P =.77), or methotrexate dose (P =.18). Nineteen of 22 patients (86%) had increased pain during treatment. Outside of pain, gastrointestinal side effects were the most common. Thirty-two percent of patients required more than one treatment cycle. CONCLUSION: Oral methotrexate can be used to treat ectopic pregnancy successfully, but there are few advantages to recommend its use over intramuscular methotrexate.

Abortifacient Agents, Nonsteroidal↗
PubMed2002

Mortality and morbidity associated with misdiagnosis of ectopic pregnancy in a defined Nigerian population.

Ectopic pregnancies can be very difficult to diagnose at initial admission. This paper reviewed the morbidity and mortality associated with misdiagnosis of ectopic gestation over a 15-year period (1985-99) at Ile-Ife, Nigeria. There were 380 confirmed ectopic pregnancies of 35 857 live births, giving an incidence of 10.5 per 1000 live births. Of the 380 cases, 38 (10%) were misdiagnosed initially at presentation. Mistaken diagnoses include pelvic inflammatory diseases, cholera, acute appendicitis, typhoid enteritis, incomplete septic abortion, uterine fibroid with menorrhagia, malaria, gastroenteritis, peptic ulcer and intestinal obstruction. There were five maternal deaths among the 38 misdiagnosed cases compared to two maternal deaths among the 342 initially correctly diagnosed cases. Significant morbidity included prolonged hospital stay, increased hospital costs and an enterocutaneous fistula. To improve the chances of correct diagnosis at initial admission, accurate menstrual and sexual history should be obtained. Facilities for improved diagnosis such as serum beta HCG and transvaginal ultrasonography should be provided. Colleagues from other specialities should be educated to increase their suspicion of ectopic pregnancy in any woman of childbearing age and perform the appropriate investigations.

Diagnostic Errors↗
PubMed1998

Dental abnormalities and ectopic eruption in patients with isolated cleft palate.

The aim of this study was to evaluate the influence of cleft size and surgical treatment on the development of permanent teeth in patients with isolated cleft palate. The series comprised 109 children with isolated cleft palate, 70 girls and 39 boys, including 14 patients with Robin sequence. The patients were grouped according to the sagittal extent of the palatal cleft, measured on dental casts obtained before the primary palate surgery. Forty-six children were treated by one-stage palatoplasty, and 63 in two stages. The dentition was studied on orthopantomograms taken at 5, 8, 11, and 14 years of age. Congenitally missing permanent teeth (third molars excluded) were found in 33 subjects (30%). Children with large clefts had significantly more missing teeth than children with small clefts. The tooth most usually missing was the mandibular second premolar, followed by the maxillary lateral incisor, and the upper second premolar. The incidence of dental malformation was 23%, mostly mild forms. Ectopic eruption of the upper first permanent molars was seen in 23 (45%) of the subjects with large clefts, and in 18 (31%) of those with small clefts. The surgical method did not significantly affect the direction of the eruption. There is a correlation between cleft size and hypodontia, dental deformity, and ectopic eruption. Children with Robin sequence had almost the same incidence of hypodontia, malformed teeth, and ectopic eruption as children with large clefts. There was no correlation between surgical method and ectopic eruption of the maxillary first permanent molars.

Adolescent↗
PubMed1985

Immunohistochemical demonstration of placental hormones in the diagnosis of uterine versus ectopic pregnancy.

The authors find that immunohistochemical demonstration of placental hormones in endometrium is useful in the identification of trophoblast independent of the presence of chorionic villi. Human chorionic gonadotropin (HCG) and human placental lactogen (HPL) are markers for trophoblastic cells. The markers were studied in 21 cases of gestational endometrium without villi in which the clinical differential diagnosis was ectopic pregnancy versus missed or incomplete uterine abortion. Trophoblastic cells were identified in four cases by routine microscopy and in an additional seven cases using the markers. In none of these cases was there a subsequent demonstration of ectopic pregnancy. In six of the ten negative cases, ectopic pregnancies subsequently were removed. Thus, the use of these hormone markers in endometrial specimens increases precision in the diagnosis of uterine versus ectopic pregnancy.

Abortion, Incomplete↗
PubMed1999

Preliminary results on the role of embryonic human chorionic gonadotrophin in corpus luteum rescue during early pregnancy and the relationship to abortion and ectopic pregnancy.

The precise mechanisms by which corpus luteum (CL) function is modulated during early pregnancy are not known. Evidence in failed pregnancies (ectopic, abortions), shows that factors other than human chorionic gonadotrophin (HCG) could be involved in its regulation. The objective of this study was to investigate the dynamics of beta-HCG, progesterone and oestradiol production in early pregnancy and its relation to embryonic quality and topographic localization. Plasma concentrations of progesterone, oestradiol and beta-HCG were studied between days +12 and +21 after an in-vitro fertilization (IVF) embryo transfer in 11 intrauterine pregnancies, 10 intrauterine abortions and seven tubal pregnancies. Tubal pregnancies and abortions were grouped according to doubling time (DT) of HCG. Results showed that oestradiol concentrations were apparently reduced in both ectopic pregnancies and abortions compared with normal pregnancies. The fall in oestradiol concentrations was seen in ectopic pregnancies with an abnormal DT for HCG and in all abortions. When the ectopic pregnancy had a normal DT, oestradiol and progesterone concentrations were normal. In abortions, the fall in oestradiol and progesterone concentrations was less influenced by the DT of HCG. These findings suggest that corpus luteum function depends on an adequate DT of HCG more than an absolute value, and with normal trophoblastic tissue the site of implantation does not affect CL function.

Abortion, Spontaneous↗
PubMed2001

Rare association of ovarian implantation site for patients with heterotopic and with primary ectopic pregnancies after ICSI and blastocyst transfer.

Two cases of patients with ruptured ovarian pregnancies (P1 = ovarian heterotopic and P2 = primary ovarian ectopic) after intracytoplasmic sperm injection and blastocyst transfer are presented. Laparoscopy was performed on day 40 and day 27 after transfer in cases P1 and P2 respectively. In both cases the ectopic pregnancies were located on the left ovary and were successfully removed by laparoscopy preserving the ovaries. In case P1 the intrauterine pregnancy was not affected. A healthy boy was born after 37 weeks of pregnancy. In this way, potential fertility of the patients and the intrauterine pregnancy were maintained. These cases occurred during a series of blastocyst transfers in which 129 pregnancies were obtained. There were no cases of ovarian ectopic/heterotopic pregnancies from January 1996 to September 1999 in 814 pregnancies obtained from day 2 or day 3 embryo transfers. Because the ovarian ectopic pregnancies occurred in patients with day 5 embryo transfer who otherwise did not have any predisposing factors for ectopic pregnancy, it is advisable to conduct a large scale analysis of future data about the possible association between blastocyst-stage embryo transfer and the somewhat higher risk of unexpected complications of clinical outcome.

Adult↗
PubMed2005

The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery.

BACKGROUND: To evaluate the accuracy of transvaginal ultrasonography (TVS) for the detection of ectopic pregnancies (EPs) in women undergoing surgery for presumed ectopic pregnancy. METHODS: A prospective, observational study. Women were diagnosed with an EP using TVS if any of the following were noted in the adnexal region: (i) an inhomogeneous mass or blob sign adjacent to the ovary and moving separately from the ovary; or (ii) a mass with a hyper-echoic ring around the gestational sac or bagel sign; or (iii) a gestational sac with a fetal pole with or without cardiac activity. The final diagnosis was based on the findings at surgery and subsequent histology of removed tissues. RESULTS: 6621 consecutive women underwent TVS during the study; 200/6621 (3.0%) women were diagnosed as having an EP using TVS. Forty-eight non-surgically managed women were excluded from the analysis. 85.5% of women presented with symptoms and 14.5% were asymptomatic. In 88 (57.9%) cases an inhomogeneous mass or blob sign was visualized and in 20 cases (13.2%) an embryo +/- cardiac activity. Thirty-one (20.4%) had a hyper-echoic ring in the adnexa. In 11 (7.2%) cases there was no evidence of either an intra-uterine (IUP) or EP on ultrasound. Two (1.3%) IUPs were subsequently diagnosed as heterotopic pregnancies. There was no association between the presenting complaints and TVS findings. 152 surgical procedures were performed. In 5.9% (9/152) of these cases no EPs were confirmed in fallopian tube or pelvis at laparoscopy. In 9.1% (13/143) of cases an EP was visualized at surgery when not seen on the index ultrasound scan. The sensitivity and specificity of TVS to detect EP were 90.9% and 99.9%, respectively, with positive and negative predictive values of 93.5% and 99.8%, respectively. CONCLUSIONS: 90.9% of ectopic pregnancies in this study population can be accurately diagnosed using TVS prior to surgery. The diagnosis of an ectopic pregnancy should be based on the positive visualization of an adnexal mass using TVS. This should in turn result in a decrease in the number of false positive laparoscopies.

Adult↗
PubMed1995

Induced abortions and risk of ectopic pregnancy.

The relationship between induced abortions and subsequent risk of ectopic pregnancy has been analysed using data from a case-control study conducted in Milan, Italy. The cases were 158 women with a diagnosis of ectopic pregnancy confirmed by laparoscopy or laparotomy, admitted to a network of university and general hospitals. Two control groups were selected. The first one (obstetric controls) included 243 women who gave birth at term (more than 37 weeks gestation) to healthy infants at the same hospitals where the cases had been identified. The second control group (non-obstetric controls) was a random sample of 158 women of comparable age interviewed in the same calendar period, admitted to hospital for a broad spectrum of acute, non-gynaecological or obstetric conditions. A total of 35 out of 158 cases (22%) reported one or more previous induced abortions; the corresponding figures were 29 out of 243 (12%) obstetric controls and 29 out of 158 (18%) non-obstetric ones. The risk of ectopic pregnancy was higher in women reporting induced abortions: the estimated multivariate relative risks (relative risk) for any induced abortions were 2.9 [95%, confidence interval (CI) 1.6-5.3] in comparison with obstetric controls and 2.5 (95% CI 1.2-5.0) in comparison with women admitted to hospital for other conditions. The risk increased with number of induced abortions, being, compared to women with no induced abortion, 13.1 (95% CI 3.2-54.5) and 3.8 (95% CI 1.1-12.7) in women reporting two or more induced abortions when the comparison groups were respectively obstetric and non-obstetric controls. This study shows an increased risk of ectopic pregnancy after induced abortion.(ABSTRACT TRUNCATED AT 250 WORDS)

Abortion, Induced↗
PubMed1995

Non-surgical treatment of ectopic pregnancy in the sole remaining tube.

We reported on three successive cases of intrauterine term pregnancy obtained in patients with an ectopic gestation in their solitary remaining tube who were treated by three different non-surgical conservative methods: parenteral methotrexate, local injection of methotrexate combined with systemic administration, and expectant management respectively. The opposite tube had been removed because of previous tubal ectopic pregnancy. The cases, which were at a high risk of repeated ectopic implantation, are unequivocal proof of intact function of a tube after conservative non-surgical procedures for ectopic pregnancy. Thus, our report adds further evidence favouring the feasibility, the safety and fertility potential of these procedures for selected unruptured tubal gestations.

Chorionic Gonadotropin↗
PubMed1993

Operative laparoscopy for ectopic pregnancy: how experienced should the surgeon be?

The purpose of this study was to assess the efficacy of laparoscopic surgery for ectopic pregnancy in a general hospital in Paris, where most of the surgeons are still in training. During a period of 20 months, 100 cases of ectopic pregnancy were diagnosed and treated by the attending residents. Nine cases required a laparotomy due to heavy bleeding or interstitial ectopic pregnancy. Most of the other cases were treated laparoscopically, with either salpingectomy (70 cases) or linear salpingostomy (19 cases). Complications of the laparoscopic surgical procedures were rare. There was one failure of linear salpingostomy that required a second intervention (5.3% failure rate); there was one case of urinary retention that resolved after 48 h; and one case of fever above 38 degrees C that responded well to antimicrobial therapy. In conclusion, we have shown that the current notion that laparoscopic surgery is preferred to conventional abdominal surgery for the treatment of ectopic pregnancy, can be applied to a public gynaecological centre with young inexperienced residents, supervised by experienced gynaecologists.

Adolescent↗
PubMed1993

Early diagnosis of ectopic pregnancy using receiver-operator characteristic curves of serum progesterone concentrations.

The objective was to assess the usefulness of serum progesterone concentrations in the differentiation of intra-uterine (viable and non-viable) and extra-uterine pregnancies. Progesterone concentrations were prospectively measured at 4, 5 and 6 weeks gestation in 338 pregnancies which resulted in 242 viable births, 81 abortions and 15 ectopic pregnancies. Progesterone threshold analysis was performed using receiver-operator characteristic curves. The progesterone threshold value for ectopic pregnancy at 4 weeks was 5 ng/ml, at 5 weeks 10 ng/ml and at 6 weeks 20 ng/ml. A significant difference was observed between all intra-uterine versus ectopic pregnancies (P = 0.0005), but not between viable versus non-viable intra-uterine pregnancies (P = 0.37). The differences were most clearly defined at 4 weeks and decreased with increasing gestation. We conclude that serum progesterone and gestational age taken together can differentiate intra-uterine from extra-uterine pregnancies with a very high sensitivity and specificity at 4 weeks gestation, a time when ectopic pregnancies are not evident on ultrasound examination.

Abortion, Spontaneous↗
PubMed1993

Laparoscopy: a dispensable tool in the diagnosis of ectopic pregnancy?

Laparoscopy is regarded as the final decisive diagnostic test in suspected ectopic pregnancy. The new non-invasive diagnostic methods of transvaginal sonography and serum human chorionic gonadotrophin (HCG) monitoring now challenge this pivotal role of laparoscopy. In this prospective study the diagnostic value of an algorithm, combining transvaginal sonography with an HCG cut-off level between 1000 and 1500 IU/l (IRP) was tested in 208 consecutive women at risk for ectopic pregnancy. Three diagnostic categories are designated by the algorithm: intra-uterine pregnancy (n = 73), ectopic pregnancy (n = 89), and trophoblast in regression (n = 46). The latter category represents patients in whom no pregnancy could be located by transvaginal sonography, with an initial HCG concentration < 1500 IU/l, declining during follow-up. The algorithm has a sensitivity of 0.97, a specificity of 0.95, a likelihood ratio for a positive test of 19.4, and a likelihood ratio for a negative test of 0.03. The described diagnostic strategy thus proved extremely reliable in the safe management of patients at risk for ectopic pregnancy, and renders laparoscopy obsolete.

Algorithms↗
PubMed1993

Transvaginal sonography and human chorionic gonadotrophin measurements in suspected ectopic pregnancy: a detailed analysis of a diagnostic approach.

In this prospective study among 208 high-risk patients with suspected ectopic pregnancy, the diagnostic value of transvaginal sonography and serum human chorionic gonadotrophin (HCG) measurements were analysed in detail. The absence of an intra-uterine gestational sac obviously was the most constant sonographic finding among patients with ectopic pregnancy (n = 89), with a very high sensitivity (0.99) but a low specificity (0.41). The application of different HCG cut-off levels improved specificity to 1.00 for values exceeding 4500 IU/l. Clinical utility obviously decreased, as many patients presented with HCG values well below this level. The additional effect of adnexal findings was analysed. Sonographic identification of an ectopic pregnancy was very specific (0.99) but had low sensitivity (0.56) because many ectopics were not detected. The additional effect of HCG values on these results was minor. The low HCG cut-off levels advocated in recent studies are questioned by the results of our analysis: whereas the combined use of sonography and HCG measurements is shown to be of great benefit, the limitations are also documented, underlining the need for re-evaluation at intervals of patients with low HCG values. The question of which cut-off level should be used in practice, however, hinges on a difficult choice between a certain specificity and clinical utility.

Adnexa Uteri↗