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PubMed1996

Methotrexate therapy for ectopic pregnancy in adolescents.

STUDY OBJECTIVE: To determine the suitability and efficacy of methotrexate (MTX) therapy for adolescent patients with ectopic pregnancy. MATERIALS: Patients with ectopic pregnancy were treated with methotrexate, 50 mg/m2 intramuscularly. Follow-up determinations of quantitative beta hCG levels were done on days 1, 4, and 7. They were then seen weekly until beta hCG levels were less than 15 mIU/ml. PARTICIPANTS: Adolescents with ectopic pregnancy (55 patients) received MTX therapy and comprised the study group. They were compared with 186 adults similarly treated. The groups were compared for treatment outcome and for compliance with the rigid protocol requirements. MAIN OUTCOME MEASURES: Treatment success was defined as a patient who required no surgical intervention and whose beta hCG levels declined to < 15 mIU/ml. RESULTS: 85% of patients required no surgical intervention following MTX injection. Surgical intervention rates were slightly higher and success rates slightly lower for adolescent patients, but these differences were not statistically significant (p = .71). Although adult patients were more likely to have a perfect compliance rating, comparison of all compliance categories showed no significant differences (p = .17). CONCLUSIONS: MTX therapy is satisfactory for adolescent patients. It is effective, and adolescent patients are able to comply with the requirements of a rigid protocol.

Adolescent↗
PubMed2005

Amiodarone for post-operative junctional ectopic tachycardia.

BACKGROUND: Post-operative junctional ectopic tachycardia is a transient, but potentially life threatening, rapid automatic tachyarrhythmia that requires urgent and adequate treatment. In our study, we review retrospectively the use and efficacy of amiodarone for this arrhythmia over an 8-year period in our institution. METHODS AND PATIENTS: Retrospective review revealed 15 patients who were administered amiodarone for post-operative junctional ectopic tachycardia during the period. The median age was 2.6 months, with a range from 8 days to 8.1 months. The median weight was 4.6 kilograms, with a range from 2.6 to 8.2 kilograms. RESULTS: The median heart rate at diagnosis of the tachycardia was 192 beats per minute, and the range was 182 to 229 beats per minute. The biochemistry was essentially normal. The median length of time until the tachycardia was controlled was 4.5 hours, and the range was from 1 to 19.5 hours, with 13 of the 15 patients controlled within 12 hours. The median dose of amiodarone received by this time was 5.9 milligrams per kilogram, with a range from 1.0 to 25.0 milligrams per kilogram. Hypotension or bradycardia within 4 hours of commencing amiodarone were noted in 2 patients. CONCLUSION: Experience in our institution, and a review of the literature, suggests that the most rapid control of post-operative junctional ectopic tachycardia will be obtained by a bolus of amiodarone followed by an intravenous infusion. Intravenous amiodarone is generally safe, with few side effects. Reported life threatening arrhythmias, however, suggest that intravenous amiodarone should be restricted to a setting where invasive monitoring and external cardiac pacing are available.

Amiodarone↗
PubMed2003

Characterisation of ACTH related peptides in ectopic Cushing's syndrome.

Adrenocorticotrophin (ACTH) is derived by cleavage from the precursor, pro-opiomelanocortin (POMC), and depending on the degree of processing by the tissue or tumor, there is the potential for a number of ACTH-related peptides to be secreted from POMC expressing cells. Previous chromatographic approaches have indicated the presence of high molecular weight forms of ACTH in the human peripheral circulation. However a quantitative assessment of the degree of processing requires two-site immunoradiometric assays which distinguish ACTH precursors and ACTH. Using this approach, we have previously identified the precursors of ACTH (POMC and proACTH) in the circulation of normal subjects in the range 5-40 pmol/l, which suggests that processing in the normal pituitary cell is incomplete. This study aimed to examine the extent of POMC processing by tumors that give rise to Cushing's Syndrome as a means of evaluating its usefulness as a diagnostic marker. In a retrospective analysis of 86 patients with Cushing's Syndrome, 34/35 patients with pituitary tumors had low levels of ACTH precursors (below 100 pmol/l) and the mean ratio of ACTH precursors:ACTH was 5:1 which indicates that these tumors do process POMC to ACTH relatively efficiently. In ectopic Cushing's Syndrome, it is unlikely that the extra-pituitary tumor cells, process POMC as efficiently. Therefore increased prevalence of ACTH precursors in the circulation would be expected and this was substantiated by the large excess of ACTH precursors (139-18,000 pmol/l) in the circulation of the 51 patients with the ectopic ACTH Syndrome. The diagnostic accuracy of the measurement of ACTH precursors was then prospectively compared with a group of 62 patients undergoing the current "gold standard" test of inferior petrosal sinus sampling (IPSS). All those patients with ACTH precursors below a diagnostic cut-off of 100 pmol/l were subsequently shown to have pituitary tumors, whereas levels of >100 pmol/l were seen in the four patients with ectopic tumors. In comparison the IPSS had a specificity of 100% but a sensitivity of 93% and for these false negative results the ACTH precursors proved diagnostically useful. Therefore measurement of ACTH precursors offers a simple non-invasive diagnostic test for the differential diagnosis of Cushing's Syndrome which compares favourably with IPSS.

ACTH Syndrome, Ectopic↗
PubMed2002

Persistent ectopic pregnancy after linear salpingotomy: a non-predictable complication to conservative surgery for tubal gestation.

BACKGROUND: The drawback of conservative surgery for ectopic pregnancy (EP) is the risk of persistent trophoblast. The purpose was to characterize patients who develop persistent ectopic pregnancy (PEP) after salpingotomy for EP and to assess prognostic factors. METHODS: The medical records of 417 patients treated by salpingotomy for EP were reviewed. Forty-eight (11.5%) patients were diagnosed with persistent EP. The data were analyzed using the Mann-Whitney U-test, Fischer's exact test or the chi2-test. RESULTS: Of 417 women, 48 (11,5%) were treated for PEP by either repeat surgery (n = 25) or methotrexate (n = 23). Oral methotrexate failed in 4/19 cases while intramuscular (i.m.) methotrexate was successful in 4/4 cases. Women treated for PEP had a higher preoperative and a slower postoperative decline of serum human chorionic gonadotropin (hCG). Both the preoperative and the early postoperative hCG levels had a low diagnostic sensitivity (0.38-0.66) and specificity (0.74-0.77) for predicting PEP. In multivariate logistic analysis, none of the following clinical variables were predictive of PEP: duration of surgery, laparoscopic approach, history of previous EP, history of previous lower abdominal surgery, ruptured EP, pelvic adhesions, absence of products of conception at microscopy and hemoperitoneum. CONCLUSIONS: Persistent ectopic pregnancy can neither be predicted from clinical variables nor from single measurements of hCG with an accuracy sufficient for clinical use.

Abortifacient Agents↗
PubMed2001

The dental follicle in normally and ectopically erupting maxillary canines: a computed tomography study.

The subjects in the study were children who were X-rayed because of increased risk for resorption following ectopically erupting maxillary canines. One hundred and seven children 9 to 15 years of age with 156 maxillary canines that were erupting ectopically and 58 normally were investigated by computed tomography (CT) to describe the features of the dental follicles of the erupting maxillary canines. Contiguous, transverse CT scans were exposed through the maxilla in the canine region and the width and shape of the dental follicles were registered scan by scan throughout the extension of the follicle. The width and the shape of the dental follicle of the erupting maxillary canine varied greatly. The range of the maximum width, measured from the crown to the periphery of the follicle, was 0.5-7.0 mm, with a mean of 2.9 mm and a 95% confidence interval of 2.7-3.2 mm for the entire sample. No relationship was found between the width or shape of the follicles and sex, age, stage of eruption, inclination of the canine, or width of the dental arch. However, the location of the maxillary canine vis-à-vis the adjacent incisor was significantly associated with the width of the follicle, which indicated that local anatomic conditions might influence the width and shape of the follicle. The dental follicles of the ectopically erupting canines were, on average, wider than those of the normally erupting canines. The 95% confidence interval for the normally erupting canines was 2.3-2.7 mm; for the buccally erupting canines 2.4-4.1 mm; for the lingually erupting canines 2.6-3.0 mm; and for the apically erupting canines in relation to the lateral incisors 2.9-4.1 mm. Canine follicles that were wide but within normal limits did not cause deviations in adjacent teeth. Cystically degenerated dental follicles were found but were indistinguishable on the CT scans from those that had been widened physiologically. The contributions of the studied variables to the variation in the width of the dental follicle of the maxillary canine were analyzed with regression models.

Adolescent↗
PubMed1999

Transvaginal ultrasound diagnosis of a live twin tubal ectopic pregnancy.

A case of live twin tubal ectopic pregnancy diagnosed by transvaginal ultrasound is presented. This is a rare occurrence and we have calculated the incidence to be approximately 1:125,000 pregnancies. There have been more than 100 case reports of twin tubal ectopic pregnancy but only four previous reports where two foetal heart motions have been visualized. The introduction of high-resolution transvaginal ultrasound has resulted in earlier diagnosis of ectopic pregnancy and contributed to the decrease in morbidity that has occurred over recent years.

Adult↗
PubMed2001

Tubal ectopic pregnancy associated with an adenomatoid tumor.

We present a case of coexistence of an ectopic pregnancy and an adenomatoid tumor in the same fallopian tube. The adenomatoid tumor is the most common benign neoplasm of the fallopian tube, and the vast majority of ectopic pregnancies occur in the fallopian tube. However, coexistence of these two conditions is extremely rare, and there has been only one previously reported case in the English literature. In the present case, the placental tissue, consisting of chorionic villi and decidua, was present in the ampulla, and the adenomatoid tumor was found in the myosalpinx, just proximal to the implantation site, replacing a large part of the myosalpinx. The close spatial relationship of these two lesions suggests that an adenomatoid tumor could have interfered with transportation of the fertilized ovum through the tube, possibly via impaired contractile activity of the myosalpinx, and consequently caused the ectopic tubal pregnancy.

Adenoma↗
PubMed1996

A 'potentially safer' route for puncture and injection of cornual ectopic pregnancies.

Puncture and injection (usually by methotrexate) of ectopic pregnancies are relatively new modalities of treatment. Lately, these have been applied to cornual ectopic pregnancies. We describe here a proposed transvaginal ultrasound-guided puncture route, leading the needle into the cornual ectopic pregnancy, first traversing the myometrium and approaching the gestational sac from the medical aspect. After extracting the needle, there is potentially less chance for rupture and bleeding. In six of the seven injected cornual pregnancies, this technique was used without complication. The only one punctured from the lateral aspect bled and required laparoscopic intervention. This technique may enable the wider use of this treatment modality by lowering the complication rate caused by bleeding at the puncture site.

Cervix Uteri↗
PubMed1997

Doppler findings in chronic ectopic pregnancy: case report.

Chronic ectopic pregnancy is an uncommon form of tubal pregnancy manifested as a pelvic mass with minimal symptoms and a low or absent titer of human chorionic gonadotropin. For this reason, most of the reported cases have been diagnosed only after explorative laparotomy. The value of Doppler ultrasonography for preoperative diagnosis of this entity has not yet been established. We report on a 36-year-old patient who was admitted for intermittent right lower quadrant abdominal pain of 3 months' duration, and a right adnexal mass found on pelvic examination. On Doppler ultrasonography, a right complex adnexal mass was demonstrated, characterized by extensive external vascularization, aberrant vessels and arteriovenous shunting, but with no internal blood flow. Explorative laparotomy revealed a right tubal mass adherent to the omentum, and covered by numerous enlarged and tortuous blood vessels originating in the omentum. Pathological examination of the mass revealed a chronic ectopic pregnancy. The possible contribution of Doppler-specific characteristics for the diagnosis of chronic ectopic pregnancy is described and discussed.

Adnexa Uteri↗
PubMed2001

Vital signs fail to correlate with hemoperitoneum from ruptured ectopic pregnancy.

The objective was to determine correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy. A retrospective chart review of ectopic pregnancies at our urban county hospital between 1990 and 1998 was conducted. Fifty-one cases met inclusion criteria. Mean minimum systolic blood pressure (SBP) 89mmHg (range 40-118), mean maximum heart rate (HR) 101 beats/min (range 62-156). Mean volume of hemoperitoneum 1,050 mL (range 400-2,000 mL). Correlation between vital signs and volume of hemoperitoneum was poor (R(2) = 0.04 for HR, R(2) = 0.1 for SBP). Association of tachycardia with hypotension was also poor (R(2) = 0.1). Extreme individual variations were observed. If surgical decisions were made on the basis of hypotension, 38% of patients could have received either inappropriate additional studies or surgical approach. Patients with normal vital signs had a 20% chance of having class IV blood loss at surgery. HR and blood pressure do not correlate well with volumes of hemoperitoneum from ruptured ectopic pregnancy.

Adult↗
PubMed1999

Localization and significance of urokinase plasminogen activator and its receptor in placental tissue from intrauterine, ectopic and molar pregnancies.

Urokinase plasminogen activator receptor (uPAR) is a membrane-anchored protein with urokinase plasminogen activator (uPA) as the ligand. This complex induces proteolysis and remodelling of maternal decidua during placental implantation. The presence of uPAR on trophoblasts is supposed to promote adhesion, migration and invasion. In cancer tissue, high levels of uPAR are correlated with a poor prognosis. This immunohistochemical study shows the localization of uPA and uPAR in a prospective design with stereological sampling of fetal and maternal tissue from normal, ectopic and hydatidiform molar (HM) pregnancies. Cytokeratin and Ki67 were used as markers for trophoblasts and proliferating cells. Membrane-bound uPAR was observed on villous non-proliferating intermediate trophoblasts (IT) within cell columns in intrauterine and ectopic pregnancies. The corresponding proliferating IT with cytological atypia sprouting from the chorionic villi in HM was uPAR-negative. uPA but not uPAR was observed in anchoring distal IT at the attachment-point to the basal plate. In the placental bed, extravillous interstitial trophoblasts were uPA-positive but uPAR-negative. The trophoblast giant cells were both uPA- and uPAR-negative. In relation to the maternal vessels, a focal distribution for uPA and uPAR was present in the endovascular and perivascular trophoblasts. The intraluminal trophoblasts overlying endothelial cells were uPAR-positive only. In maternal tissue from intrauterine and molar pregnancies, uPAR was seen in the decidual cells in a zone facing the anchoring villi and the fibrinoid lesions with embedded trophoblasts. In contrast, the stromal cells of the fallopian tube without a decidual reaction facing the implanted gestation were uPAR-negative. Non-invaded decidual, myometrial and muscular tissue of the pregnant uterus and fallopian tube was extensively positive for uPA whereas 'pseudodecidual' cells from the intrauterine evacuate in patients with an ectopic pregnancy only showed a focal and scanty reaction for uPA. When trophoblast invasion of the decidua was present, the decidual cells were uPA-negative. A semi-quantitative assessment of the receptor was estimated in villous IT within cell columns in normal and molar pregnancies but, in conclusion, quantitative evaluation of uPAR cannot be used to predict development of post-molar persistent trophoblastic disease (PTD).

Chorionic Villi Sampling↗
PubMed2006

Do serum beta-human chorionic gonadotropin levels on day 4 following methotrexate treatment of patients with ectopic pregnancy predict successful single-dose therapy?

The purpose of this study is to assess whether serum beta-human chorionic gonadotropin (beta-hCG) levels on day 4 following methotrexate (MTX) treatment in patients with ectopic pregnancy predict successful single-dose therapy or the need for subsequent surgical intervention. Retrospective analysis of patients with ectopic pregnancies treated with MTX (50 mg/m (2)) was conducted. Inclusion criteria for MTX management were serum beta-hCG < 15,000 mU/mL, absent fetal cardiac activity, ultrasonographic gestational sac < 3.5 cm, normal liver function tests, hemodynamically stable patient with no evidence of hemoperitoneum, and informed consent. Day 1, 4, and 7 serum beta-hCG levels were obtained. Outcome parameters included successful single-dose MTX management, the requirement for multiple treatments, and whether subsequent surgery was required. Receiver operator characteristic (ROC) curves were used. P < 0.05 was considered significant throughout. Eighty-three patients were studied. Of these, 60 patients were treated successfully with single doses, 16 patients required two doses, and two patients required three doses of MTX, and five underwent surgical management. Mean day 1 serum beta-hCG levels of patients successfully treated with single-dose MTX was 3938.5 (+/- 589.2 [standard deviation]) versus 1767.65 (+/- 1237.8) mU/mL in patients requiring multiple doses of MTX therapy, ( P < 0.0001). ROC curves for serum beta-hCG levels on days 1, 4, and 7 were 0.449, 0.592, and 0.754, respectively, indicating that only day 7 serum beta-hCG levels were associated with successful single-dose MTX therapy. Serum beta-hCG levels on day 4 of MTX in patients with ectopic pregnancy do not predict successful single-dose therapy or the need for surgery.

Abortifacient Agents, Nonsteroidal↗
PubMed1988

[HCG in serum and peritoneal fluid in suspected ectopic pregnancy].

HCG was measured in peripheral serum and peritoneal fluid (PF), obtained by punction of the Douglas pouch (n = 12) or by laparoscopy (n = 14) in 26 patients with suspected ectopic pregnancy. In 10 patients with tubal pregnancy, the hCG-concentration in the PF was in every case higher than in serum. Contrary to this, in 11 disturbed and 2 normal intrauterine pregnancies the PF-hCG was lower than in serum. No hCG-gradient could be observed in 1 patient with an interstitial pregnancy. Moreover, in 2 patients with inconclusive laparoscopic findings, the PF-hCG was higher than in serum; this pointed to a probable harbouring of a suspected missed ectopic pregnancy, and treatment was therefore conservative. The PF-hCG level 35 h after i. m. application of 5000 IU hCG to non-pregnant women varied between 11 and 42% as compared to that of the serum. It is concluded that the gradient of hCG between PF and serum can be used for the verification of a suspected ectopic pregnancy in addition to other diagnostic methods.

Abortion, Spontaneous↗
PubMed2001

Serum levels of myoglobin, creatine phosphokinase, and smooth muscle heavy-chain myosin in patients with ectopic pregnancy.

STUDY OBJECTIVE: Serum markers of smooth muscle destruction have been shown to be elevated in ectopic pregnancy, but they remain of questionable clinical utility. Our goal was to determine the clinical utility of 3 markers of smooth muscle destruction: creatine phosphokinase (CPK), smooth muscle heavy-chain myosin (SMHC), and myoglobin. METHODS: This was a prospective cohort study, with consecutive enrollment of all women in the first trimester of pregnancy who presented to our urban emergency department with complaints of lower abdominal pain, vaginal bleeding, or both. Patients were excluded from the study if there was a history of recent surgery or major trauma. Data analysis included receiver operating characteristic (ROC) curve, 95% confidence intervals (CIs), and a regression model. RESULTS: A total of 378 patients were enrolled, with 61 patients diagnosed with an ectopic pregnancy, and 317 patients placed in the non-ectopic pregnancy group with other diagnoses. ROC curve analysis revealed an area under the curve of 0.56 (95% CI 0.51 to 0.61) for CPK, 0.63 (95% CI 0.59 to 0.68) for SMHC, and 0.58 (95% CI 0.53 to 0.63) for myoglobin. A regression model analyzing the effects of race, maternal age, estimated gestational age, and serum levels of human chorionic gonadotropin beta-subunit found no significant confounders. CONCLUSION: Although there is a statistically significant elevation in the serum levels of SMHC, the range of values seen is too large to allow SMHC to be a useful screening tool.

Adult↗
PubMed2003

Usefulness of pipelle endometrial biopsy in the diagnosis of women at risk for ectopic pregnancy.

OBJECTIVE: The purpose of this study was to determine the accuracy of endometrial Pipelle (Unimar) biopsy to detect chorionic villi in suspected ectopic pregnancy. STUDY DESIGN: This was a blinded prospective trial that involved 32 women who were in stable condition with suspected ectopic pregnancy. Endometrial pipelle sampling was performed before uterine dilation and curettage. Pipelle and frozen section results were compared with final disease. RESULTS: Ten of 32 patients (31%) had chorionic villi that was consistent with a miscarriage; 22 of 32 patients (69%) had none detected. Pipelle biopsy had a sensitivity of 30% (95% CI, 6.7-65.2), a specificity of 100% (95% CI, 84.5-100), a positive predictive value of 100% (95% CI, 29.2-100), and a negative predictive value of 76% (95% CI, 56.5-87). Frozen section had a sensitivity of 87.5% (95% CI, 47.3-99.7), a specificity of 100% (95% CI, 83.1-100), a positive predictive value of 100% (95% CI, 59-100), and a negative predictive value of 95.3% (95% CI, 76.1-99.8). CONCLUSION: In patients with suspected ectopic pregnancy, Pipelle sampling is not a substitute for curettage because the sensitivity and predictive values are unacceptable.

Abortion, Spontaneous↗
PubMed2003

Ambulatory diagnosis and medical management of ectopic pregnancy in a public teaching hospital serving indigent women.

OBJECTIVE: The study was undertaken to evaluate the outcomes of indigent women with possible ectopic pregnancy who were cared for in a public teaching hospital outpatient clinic by multiple residents. STUDY DESIGN: Retrospective review of patients seen in the Obstetric-Gynecologic Urgent Care Center at Harbor-UCLA Medical Center from September 1, 2000, through August 30, 2001, was performed. RESULTS: Of the 243 women being evaluated for possible ectopic pregnancy, 4 required surgical intervention during their diagnostic workup and 58 were lost to follow-up. Of the 31 women given methotrexate therapy, 25 successfully completed therapy, 2 required surgery, and 4 were lost to follow-up. Substantial investment was needed to contact patients who missed appointments. CONCLUSION: It is feasible to manage women with possible ectopic pregnancies on an ambulatory basis in a public teaching hospital, but close oversight is needed and both staff and patients must commit to significant follow-up. Local protocols can be modified to reduce the numbers of visits required.

Adolescent↗
PubMed2003

Hospital referrals with possible ectopic pregnancy: prospective observational study.

Women of reproductive age with abdominal pain represent a diagnostic challenge, especially in primary care where the decision whether to refer to hospital needs to be taken. The diagnosis of an ectopic pregnancy hinges on a combination of clinical findings and a positive urinary pregnancy test (UPT). We investigated whether non-pregnant patients with abdominal pain were being referred inappropriately to hospital to exclude ectopic pregnancy because a UPT had not been performed or had been interpreted incorrectly. In this study, of the 81 patients referred by their general practitioners (GPs) on suspicion of ectopic, 38 were not pregnant on admission and only 46% of the UPT results in hospital agreed with those reported to the GP by the patient prior to referral. Given the high sensitivity and specificity of correctly interpreted UPTs, our findings suggest that pregnancy should be confirmed before hospital referral.

Abdominal Pain↗