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PubMed2003

Enthusiasm and teamwork--the basis for increase in laparoscopic surgery for ectopic pregnancy: an Inner London district hospital experience.

Laparoscopic surgery is the gold standard in the surgical management of ectopic pregnancy. It results in lower morbidity, less impact on reproductive health and faster return to normal activity. However, laparoscopic management is not available to all women. Between April 2001 and March 2002 a prospective audit of surgical management of ectopic pregnancy was carried out; 88.7% were performed laparoscopically, most due to concerted consultant input to the care of women with ectopic pregnancy.

Adult↗
PubMed2006

Ectopic pregnancy treatment by laparoscopy, a short glimpse.

Ectopic pregnancy is a life-threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein.

Female↗
PubMed1992

Ectopic eruption of maxillary first permanent molars and association with other tooth and developmental disturbances.

The associations between tooth and eruption disturbances in four groups of children selected primarily with only one diagnosed eruption or developmental disturbance in each group was analysed. Ninety-two children were primarily diagnosed with ectopic eruption of maxillary first permanent molars, 93 children with infra-occlusion and ankylosis of primary molars, 91 children with ectopic eruption of maxillary canines, and 97 children with aplasia of premolars. Of the children studied 69-79 per cent had only a single one of the four disturbances studied. In 18-28 per cent there was one additional disturbance and in 2-3 per cent two additional disturbances. From chi square contingency tests, it was found that infra-occlusion of primary molars and aplasia of premolars exhibited a higher prevalence in both directions compared to the expected population prevalence. Ectopic eruption of maxillary canines showed a significantly higher prevalence than expected in all the other three groups. Our interpretation is that these results support the hypothesis of a common, presumably hereditary, aetiology. Thus, the four conditions studied would be different manifestations of one syndrome, each manifestation having an incomplete penetrance. With closer follow-up of the maxillary canines during the eruption period in children with some of the other three disturbances, prophylactic, or early interceptive measures may be taken and complicated orthodontic treatment be reduced or avoided.

Anodontia↗
PubMed1993

Ectopic eruption of the maxillary first permanent molars in children with cleft lip and/or palate.

The purpose of this study was to analyse the prevalence of ectopic eruption of maxillary first permanent molars in children with cleft lip and palate, and evaluate the influence of both local and genetic factors. Radiographs from 225 children, 125 girls and 100 boys, were studied. The prevalence in cleft children was found to be more than four times higher than in non-cleft children (4.3 per cent). In children with cleft lip or cleft lip and alveolar process the prevalence was 15.4 per cent and in children with cleft palate only it was 28.8 per cent. A notable finding is that the ectopically erupting molar was not related to the cleft side. In children with surgically corrected cleft lip in combination with cleft palate or with cleft palate only, the surgery may have influenced the prevalence to some extent, but the main explanation for the increased prevalence of ectopic eruption in cleft children is a genetic aetiology.

Chi-Square Distribution↗
PubMed1998

A woman with three ectopic pregnancies after in-vitro fertilization and embryo transfer.

Although a higher incidence of ectopic pregnancy has been reported after in-vitro fertilization (IVF) and embryo transfer, three ectopic pregnancies in the same woman is very rare. A patient of 32 years underwent IVF-embryo transfer six times within 3 years. Three of four conceptions resulted in ectopic pregnancies. The first involved simultaneous intrauterine and left tubal pregnancy, the second was a right tubal pregnancy, and the third was a right interstitial pregnancy. In IVF-embryo transfer, bilateral salpingectomy does not remove the risk of interstitial or cornual pregnancy.

Adult↗
PubMed2002

Laparoscopic microsurgical anastomosis of the blocked, solitary post-ectopic Fallopian tube: case report.

The surgical options for the management of ectopic pregnancy include linear salpingotomy or salpingectomy. If salpingotomy is performed, subsequent tubal blockage may result and if this occurs in a solitary Fallopian tube then assisted reproductive technology is recommended as the treatment of choice. We describe a case report detailing the application of laparoscopic microsurgical tubal reanastomosis in two patients with post-ectopic blockage in a solitary Fallopian tube. Both patients conceived post-operatively and subsequently delivered term pregnancies. Laparoscopic microsurgery offers an alternative to assisted reproductive technology in patients with post-ectopic tubal obstruction in a single Fallopian tube.

Adult↗
PubMed2003

Medical treatment of ectopic pregnancies: a randomized clinical trial comparing methotrexate-mifepristone and methotrexate-placebo.

BACKGROUND: Medical treatment of ectopic pregnancies is common. To increase the efficacy of methotrexate, the association of mifepristone has been proposed. METHODS: We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo. RESULTS: A total of 212 ectopic pregnancies was randomized. There was no significant difference in the initial characteristics between the two groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n = 113) and the methotrexate-placebo group (n = 99): 79.6% (90/113) versus 74.2% (72/97) respectively, RR (95% CI): 1.07 (0.92-1.25), P = 0.41, non-significant. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was >/=10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with an 83.3% success rate (15/18) versus 38.5% (5/13) respectively. CONCLUSIONS: Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and baseline serum progesterone suggested that this combination could be limited to ectopic pregnancies associated with high serum progesterone concentrations.

Abortifacient Agents, Nonsteroidal↗
PubMed2004

Ectopic pregnancies in Caesarean section scars: the 8 year experience of one medical centre.

BACKGROUND: Our aim was to supplement the mostly individual case reports on the rarely occurring and life-threatening condition of ectopic pregnancy developing in a Caesarean section scar. METHODS AND RESULTS: Eight of all the patients treated in our department between 1995 and 2002 had been diagnosed for ectopic pregnancy that developed in a Caesarean section scar. They comprised this case series group. Four of them underwent methotrexate treatment; one had expectant management, one transcervical aspiration of the gestational sac and two by open surgery. All the non-surgically treated women had an uneventful outcome. One underwent a term Caesarean hysterectomy and the other first trimester hysterotomy and excision of the pregnancy located in the scarred uterus. Analysis of all these women's obstetric history revealed that five of them (63%) had been previously operated because of breech presentation, one had a cervical pregnancy and one had placenta previa. Four of them (50%) had multiple (> or = 2) Caesarean sections. CONCLUSIONS: The women at risk for pregnancy in a Caesarean section scar appear to be those with a history of placental pathology, ectopic pregnancy, multiple Caesarean sections and Caesarean breech delivery. Heightened awareness of this possibility and early diagnosis by means of transvaginal sonography can improve outcome and minimize the need for emergency extended surgery.

Adult↗
PubMed2000

HLA-G expression in extravillous trophoblasts is an intrinsic property of cell differentiation: a lesson learned from ectopic pregnancies.

Human leukocyte antigen (HLA)-G is a major histocompatibility gene expressed almost exclusively in extravillous trophoblasts at the fetal-maternal interface. HLA-G may play a role in protecting the fetus from attack by the maternal natural killer cells. The extravillous trophoblasts invade the decidua and maternal spiral arteries. The factors which regulate the cell-specific expression of HLA-G are unknown. In this study we asked if HLA-G is expressed in extravillous trophoblasts that develop outside of their normal cellular environment, as in the case of ectopic pregnancies. Since all ectopic pregnancies implant in the absence of underlying decidua we also used a placenta accreta as an experimental control. We found that HLA-G mRNA and protein were expressed in the extravillous trophoblasts in the 13 ectopic specimens studied. In a case of placenta accreta (which develops without decidua basalis and is therefore adherent to the underlying myometrium), HLA-G mRNA and protein were also expressed. These results suggest that HLA-G expression is induced in a cell autonomous manner rather than determined by appropriate environmental cues.

Adult↗
PubMed1998

A link between the epidemic of ectopic pregnancy and the "baby-boom" cohort.

In order to demonstrate the detailed profile of the recent epidemic of ectopic pregnancy and the subsequent decrease of the disease, the authors analyzed the changes in 5-year age groups and by 5-year age cohorts in Finland. The results describe a link between the epidemic of ectopic pregnancy and the so-called "baby boom" cohort (from 1945 to 1954) in the 1970s and 1980s, when these large age groups were in their most fertile period. The authors conclude, through its risk factors, that ectopic pregnancy is strongly correlated with age and that it exemplifies how the changes caused by large age groups play a role in the rise and fall in occurrence of certain diseases.

Adolescent↗
PubMed1996

Fertility after ectopic pregnancy: first results of a population-based cohort study in france.

The purpose of this paper was to evaluate the reproductive outcome after ectopic pregnancy (EP) from a population-based register in the centre of France. Since 1992, all the women aged 15-44 years, who permanently reside in the target area and who were treated either by surgical or medical procedures for an ectopic pregnancy in one of the area centres, have been registered and prospectively followed until 45 years of age. The analysis presented was based on the 155 women registered between January 1992 and March 1994 who were followed up for at least 6 months, and who were seeking a new pregnancy. The mean follow-up period was 16 months. A total of 102 women (66%) obtained a pregnancy. The first conception was intrauterine for 92 women, and 10 had a recurrence of ectopic pregnancy. Risk factors of recurrence were prior spontaneous abortion and prior tubal damage. For those women who conceived, the mean time to obtain pregnancy ('time to pregnancy') was 4.8 months. The 1 year cumulative intrauterine pregnancy rate (i.e. the probability of obtaining an intrauterine pregnancy within 1 year of seeking pregnancy) was 70%. After multivariate analysis by a Cox regression, the factors associated with higher fertility were age < 30 years, high educational level and no prior tubal damage.

Adolescent↗
PubMed1996

Ectopic pregnancy after in-vitro fertilization is characterized by delayed implantation but a normal increase of serum human chorionic gonadotrophin and its subunits.

We studied the dynamics of serum human chorionic gonadotrophin (HCG) and its free alpha (HCG alpha) and beta (HCG beta) subunits in 49 early pregnancies achieved by in-vitro fertilization (IVF) and embryo transfer. Of the 49 early pregnancies, nine were normal singleton pregnancies, 11 were twin pregnancies, 11 were ectopic, eight ended in a clinical (spontaneous) abortion and 10 ended in a preclinical abortion. The HCG, HCG alpha and HCG beta concentrations in serum were measured on days 12, 19 and 26 after embryo transfer. Most ectopic pregnancies could be distinguished from singleton (and twin) pregnancies on the basis of low HCG concentrations by 12 days after embryo transfer, but clinical abortions could not be distinguished from singleton pregnancies. In general, the measurement of HCG alpha and HCG beta and the molar ratios of the various forms provided only marginal additional value to that obtained from HCG, but on days 19 and 26 after embryo transfer HCG alpha was the most sensitive indicator of a normal pregnancy after IVF and embryo transfer. We conclude that in ectopic pregnancies the concentrations of HCG, HCG alpha and HCG beta increase as expected but 1.5 days later than in normal pregnancies. This appears to be the result of a delay in implantation.

Abortion, Spontaneous↗
PubMed1995

Identification of hormonal parameters for successful systemic single-dose methotrexate therapy in ectopic pregnancy.

Single-dose methotrexate is an alternative to surgery in treating ectopic pregnancy. Because success rates vary, we sought to identify factors which predict treatment outcome. A total of 44 women with ectopic gestation were treated. The non-laparoscopic diagnosis of ectopic pregnancy was made following history, physical examination, ultrasound, endometrial biopsy and the measurement of serial beta-human chorionic gonadotrophin (HCG) and progesterone concentrations. Methotrexate (50 mg/m2 i.m.) was administered, with a second dose given 1 week later in patients with plateauing or rising beta-HCG concentrations. Of 44 patients, 23 (52.3%) were successfully treated with one dose. An additional 10 women (22.7%) were also successfully managed but required a second dose, giving an overall success rate of 75.0%. In all, 11 women (25.0%) required surgery, four of whom experienced tubal rupture. Receiver operator curves were constructed to optimally select pretreatment beta-HCG and progesterone cut-off concentrations for successful treatment. Using beta-HCG < 1500 IU/l or progesterone < 7.0 ng/ml (22.3 nmol/l) as a cut-off concentration produced a diagnostic test with a sensitivity of 87.5%, a specificity of 90.0%, a positive predictive value of 96.6% and a negative predictive value of 69.2%. Conversely, this model predicts that patients with serum beta-HCG concentrations > or = 1500 IU/l and progesterone concentrations > or = 7.0 ng/ml are at far greater risk of failing single-dose methotrexate therapy.

Adult↗
PubMed1986

In-vitro fertilization and embryo transfer: a collaborative study of 1163 pregnancies on the incidence and risk factors of ectopic pregnancies.

In a multi-centric study undertaken on 1163 pregnancies obtained by in-vitro fertilization, a 5% risk of ectopic pregnancies was observed. This figure is certainly higher than that admitted for natural reproduction. After simultaneous adjusting for all variables in our data by means of a multiple logistic regression technique, two factors have specific influence: the therapeutic use of clomiphene citrate which increased the rate of ectopic pregnancies from 3 to 6% and the number of patent Fallopian tubes with a change in ectopic pregnancies rate from 3 or 4% (with 0 or 2 patent tubes) to 13% (with one patent tube). These results suggest various physiologic hypotheses as well as therapeutic considerations.

Clomiphene↗
PubMed1990

Rare ectopic pregnancies after in-vitro fertilization: one unilateral twin and four bilateral tubal pregnancies.

Between 1985 and 1989, one unilateral twin and four bilateral tubal pregnancies were encountered among 124 extrauterine pregnancies and 1648 intrauterine pregnancies following in-vitro fertilization and embryo transfer. The two factors associated with this high incidence of single and multiple extrauterine pregnancies were tubal damage and multiple embryo transfer. Embryos at different stages of development appear to have the capacity to implant ectopically. Despite advances in diagnostic capabilities, ectopic pregnancy remains a major cause of maternal mortality. Early diagnosis prior to rupture must be made if mortality and morbidity are to be abolished. The use of transvaginal sonography has improved the diagnosis of ectopic pregnancy and should be routinely used in all pregnancies following assisted conception. The identification of an intrauterine pregnancy should not be sufficient to rule out the possibility of an extrauterine pregnancy or even bilateral tubal pregnancies.

Adult↗
PubMed1994

Treatment of ectopic pregnancy: the new gynaecological dilemma.

Recent diagnostic advances have resulted in earlier and more consistent diagnosis of ectopic pregnancy. This may be responsible, in part, for the increasing incidence of the condition. Also, early diagnosis of ectopic pregnancies has prompted conservative surgical treatment, the use of medical therapy and even expectant management in selected cases. The present article analyses the following main controversial questions concerning the management of ectopic pregnancy: whether to treat or not, and how to apply expectant management; whether therapy should be conservative or radical; whether conservative management should be surgical or medical; whether surgical intervention should be laparotomic or laparoscopic; and whether medical therapy should be systemic or local.

Female↗
PubMed1998

Surgical and medical management of tubal and non-tubal ectopic pregnancies.

This article highlights recent findings in the diagnosis and management of ectopic pregnancy. While the search for the ideal biochemical marker for ectopic pregnancy continues, new protocols have been described for the management of persistent ectopic pregnancy. The role of nuclear marker Ki-67 in trophoblastic proliferation and the only randomized trial to date involving systemic methotrexate and laparoscopic surgery are discussed. The management of cervical, interstitial and heterotopic pregnancies are reviewed.

Female↗
PubMed2000

Ectopic pregnancy: an update.

This review addresses recent publications that investigate etiology, epidemiology and different modalities in diagnosis and therapy for ectopic pregnancy. A significant proportion of recent work has focused in the development of new diagnostic tools to aid in the early detection of ectopic pregnancy. Diagnostic modalities have included systemic and local markers, vascular endothelial growth factor, vascular cell adhesion molecule-1, urokinase plasminogen activator receptor, cervical fetal fibronectin, and hormonal level determinations. In addition, magnetic resonance imaging, ultrasonography, color flow mapping and endometrial thickness have been evaluated. New studies have investigated controversial issues related to the cost of the medical versus surgical treatment and the use of different medications and techniques for the management of ectopic pregnancy. Most important of all, several lines of investigation have addressed the use of human chorionic gonadotropin, algorithms, and scoring systems as prognostic indicators of successful therapy and to determine the risk of complications. The management of cervical, interstitial and heterotopic pregnancy is evaluated in this review and a summary of recent proposed diagnostic tools and concepts in management is also presented.

Female↗