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PubMed2002

Ectopic pro-opiomelanocortin syndrome.

Ectopic POMC syndrome remains one of the most challenging differential diagnoses in endocrinology. Recent progress in the understanding of the tissue specific regulation of POMC gene expression and new insights into the processing of the POMC peptide in nonpituitary tissues has helped elucidate some of the molecular events leading to ectopic expression and secretion of POMC peptides. Corticotropin and other POMC-derived peptides have diverse effects on adrenal steroidogenesis, growth, and extra-adrenal tissues. Differences in POMC gene regulation in the corticotrope versus ectopic POMC-producing tumors provides a scientific framework for the clinical distinction between eutopic and ectopic Cushing's syndrome. In an attempt to revisit recent basic and clinical advances in the diagnosis of ectopic POMC syndrome the authors undertook an extensive literature review of 530 cases in 197 published papers and provided a molecular biologic, demographic and diagnostic update. According to this review, the four most common causes of ectopic POMC syndrome are the small cell carcinoma of the lung (27%), bronchial carcinoids (21%), islet cell tumor of the pancreas (16%), and thymic carcinoids (10%). Although the clinical features of patients with ectopic POMC syndrome are similar to those with Cushing's disease, subgroup analysis reveals a broad spectrum of severity and progression of signs and symptoms of hypercortisolism. The endocrine workup of a patient with suspected ectopic POMC syndrome includes the establishment of pathologic hypercortisolism, diagnosis of corticotropin dependency, and the differential diagnosis of corticotropin-dependent Cushing's syndrome. The use of a variety of baseline endocrine values, dynamic endocrine testing, and invasive procedures leads to the correct diagnosis in the majority of patients with ectopic POMC syndrome. Diagnostic imaging, including conventional radiological techniques and somatostatin receptor scintigraphy, aids in the correct localization and eventual treatment of ectopic POMC production.

Adenoma, Islet Cell↗

PubMed2005

Assessment of cerebral autoregulation from ectopic heartbeats.

Transfer function analysis of spontaneous fluctuations in BP (blood pressure) and CBFV (cerebral blood flow velocity) has been widely used to study dynamic CA (cerebral autoregulation). The inverse Fourier transform and its integral, giving the impulse and step responses, have been used to gain perspective of the state of dynamic CA from the frequency and time domains respectively. The occurrence of ectopic heartbeats in the data has usually been treated as an artefact. Data containing multiple ectopic heartbeats were selected from a data set compiled for an acute stroke study which also included bilateral middle CBFV, concurrent surface ECG and non-invasive beat-to-beat BP recordings. Transfer function analysis and impulse and step responses were calculated from these data by (i) retaining ectopic heartbeats, (ii) after removal of ectopic heartbeats and replacement by linear interpolation, and (iii) using a narrow window of data surrounding selected ectopic heartbeats. Coherent averaging of the raw data of the selected ectopic heartbeats also allowed direct visualization of the relationship between BP changes and CBFV. The impulse and step responses were similar in shape whether or not ectopic heartbeats had been removed and showed characteristics of active dynamic CA. Removal of ectopic heartbeats from the CBFV and BP tracings, by linear interpolation or other methods, is not necessary to provide reliable estimates of dynamic autoregulation in subjects with ectopic heartbeat rates of up to eight per min. Additionally, impulse-like disturbances of BP induced by single-beat ectopic heartbeats provide enough information to characterize the autoregulatory response of the subject in agreement with more traditional methods of dynamic autoregulation assessment.

Aged↗

PubMed1995

Ectopic ureter opening into the seminal vesicle in an infant: a case report and review of the Japanese literature.

A case is presented of an ectopic ureter opening into the seminal vesicle associated with hypodysplastic kidney in an infant. We reviewed 135 cases (139 ureteral units) of male ectopic ureter from the Japanese literature and, of the 139 ectopic ureters, 109 were single-system ectopic ureters, and 26 ureters were associated with the ureteral duplication. Sixty-three and 73 ureters opened into the urinary tract and seminal tract, respectively. In patients 15 years or older, 65 cases of ectopic ureter opened into the seminal tract and 33 cases opened into the urinary tract, whereas in children under 15 years, the ectopic orifice was located more often in the urinary tract (26 cases) than in the seminal tract (8 cases). Presenting symptoms differed according to the location of the ectopic orifice. Ectopic ureters opening into the urinary tract most often presented with urinary tract infection and abdominal or lumbar pain. On the other hand, voiding and ejaculatory symptoms as well as perineal or genital pain were characteristic in ectopic ureters opening into the seminal tract. Of the 83 associated renal segments that were surgically removed, dysplasia, hypoplasia and aplasia were found in 22, 24, 14 cases, respectively. It was noteworthy that 48 of the 53 single ectopic ureters opening into the seminal vesicle were associated with ipsilateral renal dysgenesis.

Choristoma↗

PubMed1993

Axon terminal hyperexcitability associated with epileptogenesis in vitro. I. Origin of ectopic spikes.

1. Intracellular and extracellular recording techniques were used to study the increase in ectopic (i.e., nonsomatic) action-potential generation occurring among CA3 pyramidal cells during the kindling-like induction of electrographic seizures (EGSs) in this subpopulation of the hippocampal slice. Kindling-like stimulus trains (60 Hz, 2 s) were delivered to s. radiatum of CA3 at 10-min intervals. As EGSs developed, the frequency of ectopic firing increased markedly (by 10.33 +/- 3.29 spikes/min, mean +/- SE, P << 0.01). Several methods were applied to determine the initiation site for these action potentials within the cell (axons vs. dendrites). 2. Collision tests were conducted between known antidromic and orthodromic action potentials in CA3 cells to determine the critical period, c, for collision. Attempts were then made to collide ectopic spikes with known antidromic action potentials. At intervals less than c, ectopic spikes failed to collide with antidromic ones, in 5 of 10 cases. In these cells, this clearly indicates that the ectopic spikes were themselves of axonal origin. In the remaining five cases, ectopic spikes collided with antidromic action potentials at intervals approximately equal to c, most likely because of interactions within the complex system of recurrent axon collaterals in CA3. 3. Action potentials of CA3 pyramidal cells were simulated with the use of a compartmental computer model, NEURON. These simulations were based on prior models of CA3 pyramidal neurons and of the motoneuron action potential. Simulated action potentials generated in axonal compartments possessed a prominent inflection on their rising phase (IS-SD break), which was difficult to appreciate in those spikes generated in somatic or dendritic compartments. 4. An analysis of action potentials recorded experimentally from CA3 pyramidal cells also showed that antidromic spikes possess a prominent IS-SD break that is not present in orthodromic spikes. In addition to identified antidromic action potentials, ectopic spikes also possess such an inflection. Together with the predictions of computer simulations, this analysis also indicates that ectopic spikes originate in the axons of CA3 cells. 5. Tetrodotoxin (TTX, 50 microM) was locally applied by pressure injection while monitoring ectopic spike activity. Localized application of TTX to regions of the slice that could include the axons but not the dendrites of recorded cells abolished or markedly reduced the frequency of ectopic spikes (n = 5), further confirming the hypothesis that these action potentials arise from CA3 axons.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed1988

Ectopic pregnancy: a case-control study of aetiological risk factors.

Aetiological risk factors for ectopic pregnancies were evaluated in a prospective study of 86 consecutive patients with ectopic pregnancy and two age- and parity-matched control groups of women in normal early pregnancy; those with planned pregnancy (65 pairs) and those having legal abortion (51 pairs). Compared with women with planned pregnancy, the patients with ectopic pregnancy more often had an IUD in situ, they had less frequently used hormonal contraception, and they had more legal abortions, curettages, previous ectopic pregnancies, gynaecological operations and salpingo-oophoritis. Compared with women having legal abortion, the patients with ectopic pregnancy had favoured IUD-usage, or they had been without any contraception, and they had an increased frequency of previous ectopic pregnancies. The frequency of fertility problems was also increased in patients with ectopic pregnancy. Our results show that gynaecological pelvic operations, endometrial curettage and evacuation, gynaecological infections, and usage of IUD are important risk factors for ectopic pregnancy, and that infertility seems to be a sign of this risk. In addition, the clinical characteristics of the patients with ectopic pregnancy were similar to those of the patients having legal abortion.

Abortion, Spontaneous↗

PubMed1994

Ectopic pregnancies after in vitro fertilization and embryo transfer.

OBJECTIVE: Our objective was to analyze the risk factors, stimulation characteristics, and future fecundity of patients with ectopic pregnancies after in vitro fertilization (IVF). METHODS: We retrospectively evaluated all cases of ectopic pregnancy occurring between January 1989 and March 1993 (Cornell series 1 to 17). A case-control group of intrauterine pregnancies was used for comparison of the stimulation and transfer characteristics. RESULTS: Twenty-seven of 1123 pregnancies (2.4%) were ectopic, following 2812 fresh IVF embryo transfers, while 8 of 105 pregnancies (7.6%) were ectopic, following 405 frozen-thawed embryo transfers. Tubal factor was the cause of infertility in the majority (85.7%) of ectopic pregnancies. No difference was found between the ectopics and the matched controls in stimulation and transfer characteristics. Thirty ectopic pregnancies were ampullary, two were interstitial, two were cervical, and one was heterotopic. Twenty of the patients subsequently underwent 29 IVF attempts, with a pregnancy rate of 41.4% per transfer. CONCLUSIONS: Ectopic pregnancy after IVF appears to be related to preexisting tubal pathology; embryo transfer of cryopreserved thawed embryos in a natural cycle may result in a higher ectopic rate in these patients; in subsequent IVF cycles the intrauterine pregnancy rate of these patients is not decreased.

Adult↗

PubMed1989

Spontaneously resorbing ectopic pregnancy: preservation of human chorionic gonadotropin bioactivity despite declining steroid hormone levels.

We compared serum hormone profiles of patients with normal intrauterine pregnancies (n = 14), spontaneously resorbing ectopic pregnancies (n = 10), and viable ectopic pregnancies (n = 26). Hormone profiles were evaluated at 5 to 8 weeks' gestational age. Ectopic pregnancies were diagnosed by laparoscopy; intrauterine gestations were confirmed by ultrasonography. Immunoreactive beta-human chorionic gonadotropin, progesterone, estradiol, and 17-hydroxyprogesterone were measured by radioimmunoassay. Bioactive human chorionic gonadotropin was measured by a modified mouse Leydig cell bioassay. Diminished steroid production was noted in ectopic pregnancies; levels in serum of patients with resorbing ectopic pregnancies were lower than values expressed in viable ectopic pregnancies (p less than 0.01). Serum levels of human chorionic gonadotropin bioactivity correlated closely with immunoreactive human chorionic gonadotropin in all three groups (r = 0.81, p less than 0.01). Ratios of bioactive human chorionic gonadotropin to immunoreactive beta-human chorionic gonadotropin were similar (0.93 +/- 0.26 in resorbing ectopic pregnancies, 1.11 +/- 0.16 in viable ectopic pregnancies, and 0.90 +/- 0.10 in intrauterine pregnancies). We conclude that although reduced serum levels of steroids noted in ectopic pregnancy suggest an impairment in corpus luteum activity, diminished steroid production was not attributable to lower human chorionic gonadotropin bioactivity.

17-alpha-Hydroxyprogesterone↗

PubMed1995

IUD use and the risk of ectopic pregnancy: a meta-analysis of case-control studies.

Because of inconsistent findings among case-control studies on the relationship between IUD use and the risk of ectopic pregnancy, a meta-analysis of published literature was conducted. From 1977 through 1994, 19 publications regarding 16 studies of ectopic pregnancy and IUD use were found by MEDLINE and manual search. The odds ratio (ORs) of ectopic pregnancy with current and past IUD use in each study were pooled. A quality score system was developed to assess each study. Funnel plot was used to assess potential publication biases. For current IUD use, when cases were compared to pregnant controls, there was an increased risk of ectopic pregnancy (pooled OR: 10.63, 95% confidence interval (CI): 7.66-14.74); when cases were compared to non-pregnant controls, there was no risk of ectopic pregnancy (pooled OR: 1.06, 95% CI: 0.91-1.24). Past IUD use could mildly increase the risk of ectopic pregnancy (pooled OR: 1.40, 95% CI: 1.23-1.59). Selecting pregnant or non-pregnant women as controls, however, did not affect the OR estimates of past IUD use. Current IUD use does not increase the risk of the ectopic pregnancy. However, a pregnancy with an IUD in situ is more often an ectopic one than a pregnancy with no IUD. Past IUD use could mildly elevate the risk of ectopic pregnancy.

Adolescent↗

PubMed2005

Cost-effectiveness of presumptively medically treating women at risk for ectopic pregnancy compared with first performing a dilatation and curettage.

OBJECTIVE: To compare the cost and complication rate of two alternative strategies for the diagnosis and medical management of ectopic pregnancy when ultrasound is nondiagnostic. DESIGN: A decision tree was constructed to compare [1] dilatation and curettage (D&C) followed by treatment of all ectopic pregnancies with methotrexate versus [2] empiric treatment of all patients with possible ectopic pregnancies with methotrexate without D&C. SETTING: University setting. PATIENT(S): Ten thousand hypothetical women with nonviable pregnancies and a known incidence of ectopic pregnancy were entered into a computer model. MAIN OUTCOME MEASURE(S): The two approaches were compared with respect to the number of missed ectopic pregnancies, complications, procedures performed, admissions to the hospital, and cost. RESULT(S): The D&C group had 1% more failed managements of ectopic pregnancies and 13.4% fewer patients with a miscarriage undergo a second treatment for resolution. The D&C group had 13.7% fewer complications including 6.3% fewer hospitalizations. D&C costs $173 to $223 more than empiric use of methotrexate per patient. CONCLUSION(S): Empirically treating women at risk for ectopic pregnancy with methotrexate does not reduce complications or save money. In the absence of such savings, the desire to make an accurate and definitive diagnosis, allowing objective prognosis on future fertility and risk of repeat ectopic pregnancy, supports the need to distinguish a miscarriage from ectopic pregnancy before treatment with methotrexate.

Abortifacient Agents, Nonsteroidal↗

PubMed2003

Risk factors and clinical features of recurrent ectopic pregnancy: a case control study.

OBJECTIVE: To compare signs and symptoms between patients with recurrent and single ectopic pregnancies. DESIGN: Case-control study. SETTING: University medical center. PATIENT(S): Three hundred six women with single ectopic pregnancies and 61 women with recurrent ectopic pregnancies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Risk factors, historical factors, and findings at presentation that may predispose to recurrent ectopic pregnancy. RESULT(S): The risk of recurrent ectopic pregnancy was increased with a history of surgery, history of live birth, and history of spontaneous miscarriage and not with a history of gonorrhea, chlamydia, pelvic inflammatory disease, Caesarean section, or pregnancy termination. Patients with a recurrent ectopic pregnancy had a nonsignificant trend toward higher initial hCG values. The majority of ultrasounds in both groups were nondiagnostic on presentation. The patients with recurrent ectopic pregnancy were less likely to have bleeding on initial presentation, though both groups had similar complaints of pain. CONCLUSION(S): Secondary prevention of ectopic pregnancy is problematic because of the paucity of risk factors that can be modified to diminish the odds of recurrence. Clinicians' ability to both diagnose and counsel patients at risk for recurrent ectopic pregnancy can be optimized by awareness of the clinical features of this condition.

Abortion, Spontaneous↗

PubMed1987

Ectopic pregnancy: its relationship to tubal reconstructive surgery.

Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. The incidence of ectopic pregnancy after tubal surgery is extremely variable and is closely linked to the degree of restoration of normal functional and anatomic integrity after the surgical procedure. This depends, to a large extent, on the amount of previous damage to the tube and its potential reversibility. Major improvements in surgical technique can, therefore, have reduced, but not eliminated, the occurrence of tubal pregnancy. The incidence of ectopic pregnancy associated with any given tubal surgical procedure should be taken into consideration when surgery is contemplated. When the risk of ectopic pregnancy is unacceptably high, or when the patient is reluctant to be exposed to a high risk of ectopic pregnancy, IVF-ET could be offered as an alternative. Table 11 represents the incidence of ectopic pregnancy associated with the various surgical procedures. The figures demonstrate the wide variation in outcome for the same procedure.

Animals↗

PubMed2000

Resorption of incisors after ectopic eruption of maxillary canines: a CT study.

The purpose of the study was to analyze the extent and prevalence of resorption of maxillary incisors after ectopic eruption of the maxillary canines in a sample of subjects referred to an orthodontic specialist clinic for consultation. The subjects consisted of 107 children, 39 boys and 68 girls, between 9 and 15 years of age (mean 12.5 years), with 156 ectopically and 58 normally erupting maxillary canines. All children were subjected to a basic clinical and intraoral radiographic investigation. These radiographs were supplemented with computerized tomography (CT) of the upper alveolar bones in order to get more precise information on the positions and relationships between the maxillary canines and adjacent incisors and to evaluate resorptions on the roots of the incisors. The results showed that, relative to the roots of the adjacent incisors, the crowns of 21% the ectopically positioned canines were located to the buccal, 18% to the distobuccal, 27% to the lingual, 23% to the distolingual, 5% apically and 6% between the central and lateral incisors. Ninety-three percent of the ectopically positioned canines were in contact with the roots of the adjacent lateral incisor and 19% were in contact with the central incisor. The corresponding figures for the normally erupting canines were 49%. Resorptions on the roots of the incisors adjacent to the ectopically positioned canine occurred in 38% of the laterals and in 9% of the centrals. The resorptions were graded and tended to be extensive. Among the 58 resorbed lateral incisors, resorptions were slight in 31%, moderate in 9%, and severe with pulpal involvement in 60%. The corresponding figures for the 14 resorbed centrals were 36%, 21%, and 43%, respectively. About 60% of the resorptions involved the middle and apical thirds, the tip of the apex not included. On the sides with normally erupting canines, 3 lateral maxillary incisors were slightly or moderately resorbed distally. In all, 51 of the 107 subjects with ectopically erupting maxillary canines (48%) had resorbed maxillary incisors during the eruption of the maxillary canines. There were statistically significant correlations between ectopic eruption of the maxillary canine, contacts between the teeth and resorptions on the adjacent incisors. It was concluded that resorption on maxillary incisors after ectopic eruption of the maxillary canines is a more common phenomenon than previously reported and has to be considered in all cases with seriously diverging eruption of maxillary canines. It was also concluded that the resorptions of the roots of the incisors were caused by pressure during the eruption of the adjacent, aberrant canine. Finally, it was shown that CT scanning substantially increased the detection of root resorptions on incisors adjacent to ectopically erupting maxillary canines (about 50%). The sensitivity of intraoral films was low when diagnosing the resorptions, being calculated to 0.68.

Adolescent↗

PubMed1997

The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group.

BACKGROUND: Tubal sterilization is an increasingly common method of contraception in the United States. Although pregnancy after sterilization is uncommon, it can occur and may be ectopic. We used data from the U.S. Collaborative Review of Sterilization to estimate the risk of ectopic pregnancy in women who had undergone the common types of tubal sterilization. METHODS: A total of 10,685 women undergoing tubal sterilization were followed in a multicenter, prospective cohort study. We intended to follow all the women for 5 years by means of annual telephone interviews; for women enrolled early in the study, we attempted an additional follow-up telephone interview 8 to 14 years after sterilization. To assess the risk of ectopic pregnancy in these women, we used cumulative life-table probabilities and proportional-hazards analysis. RESULTS: There were 47 ectopic pregnancies in the 10,685 women; the 10-year cumulative probability of ectopic pregnancy for all methods of tubal sterilization combined was 7.3 per 1000 procedures. The cumulative probability varied substantially according to the method of sterilization and the woman's age at the time of sterilization. Women sterilized by bipolar tubal coagulation before the age of 30 years had a probability of ectopic pregnancy that was 27 times as high as that among women of similar age who underwent postpartum partial salpingectomy (31.9 vs. 1.2 ectopic pregnancies per 1000 procedures). The annual rate of ectopic pregnancy for all methods combined in the 4th through 10th years after sterilization was no lower than that in the first 3 years. CONCLUSIONS: A history of tubal sterilization does not rule out the possibility of ectopic pregnancy, even many years after the procedure.

Adolescent↗

PubMed2000

Early diagnosis of ectopic pregnancy: can we do it accurately using a biochemical profile?

We wanted to evaluate the utility of seven biochemical markers in the early diagnosis of ectopic pregnancy. Women with pain and bleeding suspicious for ectopic pregnancy were evaluated prospectively. Each woman had a transvaginal sonogram and serum determination of beta-human chorionic gonadotropin (beta-hCG), progesterone, estradiol (E2), creatine phosphokinase (CPK), CA-125, 17-hydroxyprogesterone, and androstenedione. The women were grouped in two ways, and there was considerable overlap between the two groups. One grouping included those with <45 days of amenorrhea, and the other included those whose beta-hCG was <2500 mIU/ml. Each marker was analyzed by univariate and multivariate logistic regression to see which could best distinguish ectopic pregnancies from nonectopic pregnancies. In the group of women with <45 days of amenorrhea, ectopic pregnancies were distinguished by a low progesterone and a high CPK. None of the other biochemical markers were significantly associated with ectopic pregnancy in the multivariate logistic regression analysis. A receiver operating characteristic (ROC) curve was constructed for the CPK/progesterone ratio. As an example of different cut points, a CPK/progesterone ratio >15 was 87% sensitive and 83% specific in the diagnosis of ectopic pregnancy. In the group of women with beta-hCG <2500 mIU/ml, the only biochemical marker found to be significantly associated with ectopic pregnancy was CPK. An ROC curve was constructed for CPK in this group. As an example of different cut points, a CPK >70 had a 78% sensitivity and 81% specificity in the diagnosis of ectopic pregnancy. We conclude that the CPK/progesterone ratio is helpful in those women with <45 days of amenorrhea, and serum CPK levels are helpful in women whose beta-hCG is <2500 mIU/ml. Although serum levels of CPK and the ratio of CPK/progesterone are the most helpful in making the diagnosis of early ectopic pregnancy, they are not good enough to be used alone in clinical practice.

17-alpha-Hydroxyprogesterone↗

PubMed2003

Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France.

This case-control study was associated with a regional register of ectopic pregnancy between 1993 and 2000 in France. It included 803 cases of ectopic pregnancy and 1,683 deliveries and was powerful enough to investigate all ectopic pregnancy risk factors. The main risk factors were infectious history (adjusted attributable risk = 0.33; adjusted odds ratio for previous pelvic infectious disease = 3.4, 95% percent confidence interval (CI): 2.4, 5.0) and smoking (adjusted attributable risk = 0.35; adjusted odds ratio = 3.9, 95% CI: 2.6, 5.9 for >20 cigarettes/day vs. women who had never smoked). The other risk factors were age (associated per se with a risk of ectopic pregnancy), prior spontaneous abortions, history of infertility, and previous use of an intrauterine device. Prior medical induced abortion was associated with a risk of ectopic pregnancy (adjusted odds ratio = 2.8, 95% CI: 1.1, 7.2); no such association was observed for surgical abortion (adjusted odds ratio = 1.1, 95% CI: 0.8, 1.6). The total attributable risk of all the factors investigated was 0.76. As close associations were found between ectopic pregnancy and infertility and between ectopic pregnancy and spontaneous abortion, further research into ectopic pregnancy should focus on risk factors common to these conditions. In terms of public health, increasing awareness of the effects of smoking may be useful for ectopic pregnancy prevention.

Adult↗

PubMed1995

Analysis of the incidence and risk factors associated with ectopic pregnancy following in-vitro fertilization and embryo transfer.

Ectopic pregnancy is a well known complication of in-vitro fertilization (IVF) and embryo transfer. From March 1983 to December 1993, 3000 clinical pregnancies were achieved at Bourn Hall Clinic, including 135 ectopic pregnancies (4.5%). Of these ectopics 20 were heterotopic, eight ovarian, six bilateral tubal and the remainder were singleton tubal pregnancies. The main risk factor identified in the series was a history of pelvic inflammatory disease (P < 0.001). The data also showed that ectopic pregnancy is at present more prevalent among patients in whom tubal damage is the reason for treatment. There was slight statistical evidence (P = 0.05) that patients having ectopic pregnancies received a higher volume of culture medium than those having normal deliveries. There was also an apparent trend (P = 0.07, not significant) that high progesterone/oestradiol ratio on the day of embryo transfer was associated with ectopic pregnancy. There was no statistical evidence of association between ectopic pregnancy and a history of ectopic pregnancy, abortion, still birth, termination of pregnancy, neonatal death, tubal surgery, ovarian stimulation protocol, plasma concentration of oestradiol, luteinizing hormone and progesterone, number of oocytes retrieved, number or quality of embryos transferred, administration of general anaesthesia for embryo transfer, and the number of patent Fallopian tubes. Awareness of the risk factors associated with ectopic pregnancy plays an important part in the early diagnosis of this potentially fatal condition.

Adult↗

PubMed1996

Transvaginal intratubal methotrexate treatment of ectopic pregnancy. Report of 100 cases.

Between November 1988 and December 1993, 100 patients with a common, unruptured ectopic pregnancy were treated with 1 mg/kg injection of intratubal methotrexate under transvaginal sonographic control. Patients were not excluded from this series on the basis of the size of the adnexal mass, the term of ectopic pregnancy or initial beta-human chorionic gonadotrophin (HCG) concentrations. Patients were excluded following uncertain diagnosis, signs of a ruptured ectopic pregnancy, or a significant haemoperitoneum on ultrasound scans. The mean age of the patients was 29.5 years (range 20-41). The mean gestational age and initial HCG concentration were 7.5 weeks (5-11) and 11,614 mIU/ml (192-105,000 respectively). Of the 100 patients, 22 (22%) had an ectopic pregnancy with active cardiac activity. Complete resolution was obtained in 78 out of these 100 ectopic pregnancies. Of these, 66 patients (85%) needed only one intratubal methotrexate injection, and 12 patients (15%) required a second i.m. methotrexate injection of 1 mg/kg. In this study, local treatment with one single intratubal methotrexate injection was successful in only 66% of patients. The mean resolution time for reduction of beta-HCG concentrations was 23.5 days (range 7-40). There was no statistically significant correlation between initial beta-HCG concentrations and outcomes after methotrexate treatment of ectopic pregnancy in our study. Where embryonal heart beats were observed, the success rate of the procedure was 40.9% (nine out of 22 cases). In the absence of cardiac activity, or when ultrasound examination showed no embryo, the success rate achieved was 84.6% (66 out of 78 cases) (P < 0.01). In all, 34 patients were considered to be incompletely cured after only one intratubal methotrexate injection: 12 patients required a second i.m. injection, a stagnation of beta-HCG concentrations was observed in 15 patients, abdominal pain occurred in six patients, and one patient suffered tubal rupture with haemoperitoneum. A total of 22 patients required secondary surgical management (salpingectomy). No biochemical or clinical side-effects of methotrexate treatment occurred. Tubal alteration ascribable to methotrexate injection occurred in one patient in our study. Out of 75 patients in this series who wished to conceive, 21 (28%) became pregnant within 1 year with the following outcomes: 11 pregnancies at term, three miscarriages, one induced abortion and six recurrent ectopic pregnancies (four occurred on the same side). Our findings suggest that treatment of common unruptured ectopic pregnancy without prior selection of patients, by a single intratubal methotrexate administration was associated with a 66% success rate. This was dependent only on the presence of embryonal heart beats and there was no correlation between the success rate and initial beta-HCG concentrations. Successful outcome after methotrexate administration for ectopic pregnancy could be perfected by way of an improved selection of patients based on inactive embryonal hearts and absence of a visualized embryo.

Adult↗

PubMed1998

The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy: a meta-analysis.

Serum progesterone measurement has been advocated as a diagnostic tool in the non-invasive diagnosis of ectopic pregnancy. To assess the accuracy of a single serum progesterone measurement in the diagnosis of ectopic pregnancy, a meta-analysis was performed incorporating 26 studies evaluating the performance of single serum progesterone measurement in the diagnosis of ectopic pregnancy. A distinction was made in the diagnosis of pregnancy failure of any type versus viable intrauterine pregnancy and the diagnosis of ectopic pregnancy versus non-ectopic pregnancy. The reported sensitivity and specificity differed between the studies. Since there was a clear negative correlation between sensitivity and specificity, summary receiver-operating characteristic (ROC) curves could be estimated. The ROC curve for the diagnosis of pregnancy failure versus viable intrauterine pregnancy showed a good discriminative capacity. Single serum progesterone measurement could not discriminate between ectopic pregnancy and non-ectopic pregnancy. It is concluded that serum progesterone measurement can identify patients at risk for ectopic pregnancy, who need further evaluation, but its discriminative capacity is insufficient to diagnose ectopic pregnancy with certainty.

Female↗