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PubMed1999

Surgical management of ectopic pregnancy.

Laparoscopic salpingostomy remains the definitive and universal treatment of ectopic pregnancy in patients who are hemodynamically stable and who wish to preserve their fertility. The reproductive performance after salpingostomy appears to be equivalent or better than salpingectomy, but the recurrent ectopic pregnancy rate may be slightly greater. Expectant management has a poor efficacy and unproven benefit in subsequent reproductive outcome. Its use should be limited to situations in which the ectopic pregnancy is suspected but cannot be detected by transvaginal ultrasound. Methotrexate is an alternative to surgical treatment in selected patients who fulfill strict inclusion criteria, including compliance with follow-up evaluation. A large, prospective, randomized trial with significant power is needed, however, to study the prognostic factors for methotrexate success. The most practical and efficient method of methotrexate administration is a single intramuscular injection. Those who do not meet the criteria for methotrexate therapy should be treated surgically, which can be done by laparoscopy. Interstitial pregnancy also can be treated with methotrexate. Otherwise, a cornual resection or salpingotomy can be done. Although, it is feasible by laparoscopy, the laparoscopic approach should be done only by those who have an expertise in laparoscopic suturing. Abdominal and ovarian pregnancies are best treated surgically. Further, the diagnosis usually is established by laparoscopy, and an appropriate surgical treatment can be conducted at the same time.

Chronic Disease↗
PubMed1997

Chorionic villi or trophoblastic tissue in uterine samples of four women with ectopic pregnancies.

The diagnosis of early ectopic pregnancy remains challenging for the gynecologist. Although early detection of a suspected pregnancy has been facilitated by quantitative beta human chorionic gonadotropin studies and ultrasonography, a patient subgroup remains with an ambiguous presentation. In this group of patients, the clinician must rely on microscopic examination of products of conception in a uterine curettage specimen to rule out the presence of an extrauterine pregnancy. The presence of an implantation site, chorionic villi, or trophoblastic tissue in uterine curettage samples is conventionally held as definitive evidence of an intrauterine pregnancy. We present a series of four cases that challenge this convention. In these cases, chorionic villi or an implantation site were identified in uterine samples of pregnant women who each ultimately proved to have an ectopic pregnancy. If clinical suspicion is high, the finding of either chorionic villi or an implantation site should not preclude further workup of a possible ectopic pregnancy. In cases where only a few villi or a single chorionic villus are identified, other signs of intrauterine implantation such as intermediate trophoblastic cells, hyalinized vessels, and a fibrinoid matrix should be sought to establish firmly the diagnosis of an intrauterine pregnancy.

Adult↗
PubMed1980

Tumor hypercalcemia and "ectopic hyperparathyroidism".

1. All available evidence for and against the concept of ectopic hyperparathyroidism, including 307 case reports of tumor hypercalcemia, was collated. 2. Of 104 combined cases of tumors of the kidney, lung, liver, head, neck and esophagus, 91 (88%) were in men. 3. The parathyroid glands were examined in 170 of 307 cases and parathyroid hyperplasia or adenoma were described in 34 cases. This high frequency may reflect higher likelihood of reporting such association. 4. Analysis of the histological pattern of tumors associated with humoral hypercalcemia revealed a marked association with certain histological types in different organs, such as clear-cell carcinoma of the kidney and ovary, hepatocarcinoma and cholangiocarcinoma, pheochromocytoma, and squamous-cell carcinoma of the lung, head, neck, esophagus, and urogenital tract. This histological correlation is not compatible with the "random derepression" hypothesis. 5. The existence of tumor humoral hypercalcemia is well documented, as 61 of 74 operated patients sustained remission of hypercalcemia following tumor removal. 6. The evidence for ectopic PTH being produced by tumor is not well documented and is based on conflicting radioimmunoassay results. We have found no case in the literature which fulfilled unequivocally criteria of ectopic production of biologically active PTH. There has been a lack of studies of tumors for the presence of biologically active hypercalcemic factors because only relatively insensitive bioassays are available at present. More information is also required on microscopic bone changes in tumor hypercalcemia as x-ray studies alone are inadequate. 7. On the basis of the present evidence, causes and mechanisms of tumor hypercalcemia are likely to be multiple.

Adrenal Gland Neoplasms↗
PubMed1979

The radioreceptor assay for hCG in ectopic pregnancy.

The Biocept-G test (Wampole) is a commercial modification of the radioreceptor assay for human chorionic gonadotropin (hCG) which takes 1 hours to process and has a sensitivity of 200 mIU/ml for hCG. Over a 9 1/2-month period, 70 consecutive patients with proven ectopic pregnancy were evaluated by the Biocept-G test, 2-minute urine slide test, and culdocentesis. Of 67 of these patients, 94% had a positive Biocept-G test, 82% had a positive culdocentesis, and 69% had a positive urine slide test. Sixty-nine (97%) of the 70 patients had either a positive Biocept-G and/or a positive culdocentesis, while only 1.7% had both a negative culdocentesis and a negative Biocept-G. Thirty-two patients underwent laparoscopy or laparotomy during this time period to rule out ectopic pregnancy but were not found to have this condition. The Biocept-G had a 94% accuracy rate in determining the presence or absence of intrauterine pregnancy in this group, compared to an 82% accuracy rate for the urine slide test. The Biocept-G has the highest true-positive rate for ectopic pregnancy published to date for a rapidly performed, commercially available pregnancy test.

Chorionic Gonadotropin↗
PubMed1986

Treatment of persistent ectopic pregnancy with methotrexate and leukovorum rescue: a case report.

The incidence of ectopic pregnancy is increasing in the Western world, and this reproductive complication has had an adverse impact on subsequent fertility. Advances in the surgical treatment of ectopic pregnancies have been designed to preserve future reproductive potential, but conservative tubal surgery may fail to completely remove the trophoblast. Described is a case of persistent ectopic pregnancy successfully treated with methotrexate.

Adult↗
PubMed1986

Serum progesterone levels as an aid in the diagnosis of ectopic pregnancy.

Progesterone levels in 29 women with ectopic pregnancies and 20 women with early intrauterine pregnancies were evaluated using a new direct radioimmunoassay that offers results within four hours. Patients with normal intrauterine pregnancies had serum progesterone levels greater than 20 ng/mL (mean = 30.9 ng/mL) while all patients with ectopic pregnancies had progesterone levels less than 15 ng/mL (mean = 5.7 ng/mL). The incorporation of the progesterone assay into the workup of a patient with suspected ectopic pregnancy can be a useful clinical adjunct to the conventional methods of evaluation.

Chorionic Gonadotropin↗
PubMed1991

Ectopic pregnancy in an urban teaching hospital: can tubal rupture be predicted?

We evaluated the medical history, physical examination, and laboratory tests done on 245 patients with laparoscopically proven ectopic pregnancies. The absence of abdominal pain was the only clinically useful negative predictive value (91%) regarding tubal rupture. Although mean levels of serum human chorionic gonadotropin (hCG-beta subunit) were significantly higher in patients with ruptured versus unruptured ectopic pregnancies (16,612 mIU/mL vs 6406 mIU/mL), no breakpoint excluded the possibility of tubal rupture. In fact, one third of ectopic pregnancies in patients with a serum beta-hCG level below 100 mIU/mL were ruptured. We conclude that clinical symptoms and signs are poor predictors of tubal rupture. In addition, absolute values of serum beta-hCG are not helpful in excluding the possibility of rupture.

Adult↗
PubMed1998

Long-term medical treatment of ectopic ACTH syndrome.

BACKGROUND: The morbidity of hypercortisolemia due to ectopic production of ACTH by various tumors may be greater than the morbidity of the tumor itself. METHODS: We report three cases of long-term treatment of ectopic ACTH syndrome due to metastatic bronchial carcinoid, islet cell carcinoma, and malignant thymoma tumors. Clinical and biochemical eucortisolemia was achieved in each case and was sustained from 24 to 55 months. We review the therapeutic options and their reported efficacy. RESULTS: Cessation of therapy resulted in recurrence of hypercortisolemia in each case, showing the effectiveness of therapy. CONCLUSION: Long-term treatment of ectopic ACTH-induced hypercortisolemia by blocking adrenal steroidogenesis is clinically effective and well tolerated.

ACTH Syndrome, Ectopic↗
PubMed2004

A rare drug reaction to methotrexate after treatment for ectopic pregnancy.

BACKGROUND: Ectopic pregnancies are commonly diagnosed and treated in physicians' offices. In the hemodynamically stable patient, therapy often includes treatment with methotrexate. Well-known adverse effects of this drug include mucositis, abdominal cramping, and malaise. We report a case of a rare drug reaction after treatment with methotrexate. CASE: A 34-year-old, gravida 2, para 0, at 7 weeks of gestation by last menstrual period was diagnosed with an ectopic pregnancy and treated with methotrexate. The patient had an anaphylactoid reaction shortly after administration of methotrexate. CONCLUSION: Methotrexate is a commonly used therapy for ectopic pregnancies in the outpatient setting. Practitioners should be aware of the potential adverse reactions to methotrexate.

Abortifacient Agents, Nonsteroidal↗
PubMed2006

A cautionary tale: fatal outcome of methotrexate therapy given for management of ectopic pregnancy.

BACKGROUND: Medical therapy with methotrexate is a standard practice for the commonly encountered problem of ectopic pregnancy. Methotrexate is excreted predominantly by the kidney and should be used with extreme caution in renal insufficiency. All physicians who administer methotrexate must understand its mechanism of action, distribution, and elimination to minimize potential risks to the patient. CASE: A young, dialysis-dependent woman received a standard dose of methotrexate for an ectopic pregnancy. Prolonged methotrexate exposure resulted. The consequences-pancytopenia, desquamation, acute respiratory distress syndrome, and profound bowel ischemia-ultimately led to her death. CONCLUSION: Methotrexate, even at extremely low doses, can be fatal in patients with renal insufficiency. Alternative means of therapy should be sought for women with ectopic pregnancy and renal failure.

Abortifacient Agents, Nonsteroidal↗
PubMed2006

18Flurodeoxyglucose positron emission tomography in the localization of ectopic ACTH-secreting neuroendocrine tumours.

OBJECTIVE: Neuroendocrine tumours (NET) are a rare cause of Cushing's syndrome. These tumours can be very small and therefore difficult to identify. Current localization techniques include CT, MRI and radioisotope scanning, but in a proportion of cases the NET remains occult. Positron emission tomography (PET) scanning, is a relatively new imaging modality that is increasingly used to detect and monitor lesions with high metabolic activity. We report on the use of PET scanning in the evaluation of the ectopic ACTH syndrome. PATIENTS: Three patients with ectopic ACTH-dependent Cushing's syndrome with varying difficulty in NET localization are included in the report. MEASUREMENT: Positron emission tomography scanning using 18flurodeoxyglucose (FDG) identifies tissue with high metabolic activity. 18FDG-PET scanning was used in each of these patients and the imaging is presented along with biochemical data. RESULTS: In each case the NET was easily identified using 18FDG-PET, aiding clinical decision making and therapeutic outcome. A cure was identified by clinical resolution of symptoms and undetectable ACTH levels postsurgery. CONCLUSIONS: 18FDG-PET assisted in localizing small metabolically active NETs, suggesting this imaging modality may have a useful role in identifying NET causing Cushing's syndrome as a result of ectopic ACTH production.

ACTH Syndrome, Ectopic↗
PubMed1989

A hypothesis on the increasing rates of ectopic pregnancy.

Rates of ectopic pregnancy have been increasing in the developed world in recent decades. The cause of this increase is not established. There is evidence that women with ectopic pregnancies have low oestrogen levels and that tubal contractions are under oestrogenic control. Low diets and vigorous exercise both lower women's oestrogen levels. Over the last two decades, women have been increasingly engaged in physically demanding sport and in dieting. It is inferred here that there are increasing minorities of women with suboptimal hormone levels, and it is suggested that diminishing oestrogen levels (due to dieting and increasing participation in sport) have been responsible for the increasing rates of ectopic pregnancy.

Adult↗
PubMed1975

An epidemiological study of recent trends in ectopic pregnancy.

Data from two independent sources in England and Wales, the first based upon persons discharged from hospital and the second upon general practitioner consultations, indicate that the incidence of ectopic pregnancy has been increasing since the late 1950s, with a particularly sharp increase since 1970. Time trends in the age and regional distribution of ectopic pregnancy suggest that the increasing use of intrauterine contraceptive devices may be a major factor contributing to this recent increase in extrauterine gestations. In contrast, recent age and regional trends in tubal infection appear to be unrelated to the trends in ectopic pregnancy. The possible contribution of progestogen-only contraceptives, induced abortion and tubal surgery to the recent increase in extrauterine pregnancy cannot be assessed from the available data.

Abortion, Induced↗
PubMed1988

Can ultrasound reliably diagnose ectopic pregnancy?

A total of 252 women with amenorrhoea and with abdominal pain or vaginal bleeding, or both, had an emergency high-resolution ultrasound sector scan. In 100 women the symptoms were unrelated to any identifiable abnormal ultrasound finding, none of them was pregnant and their symptoms settled spontaneously; 33 other women had follicular or luteal cysts and 30 had pelvic inflammatory disease. Histological examination confirmed an ectopic pregnancy in 60 women (24%); in seven a live fetus was observed outside the uterus allowing a confident diagnosis of ectopic pregnancy; in 27 the thickness of the endometrium was greater than 10 mm (sensitivity 50%, specificity 84%, positive predictive value 28%, negative predictive value 87%); in 15 the uterine area measurement was less than 20 cm2 (sensitivity 72%, specificity 41%, positive predictive value 20%, negative predictive value 79%); and 43 had an adnexal mass volume greater than 10 ml separate from the ovary (sensitivity 85%, specificity 37%, positive predictive value 23%, negative predictive value 90%). Only three had negative ultrasound findings. The negative predictive value of an ultrasound examination could be increased to 96% by using a combination of these ultrasound features. The addition of hCG (greater than 25 i.u./l) improved the specificity to 98% and the negative predictive value to 100%. These criteria may improve the ultrasound diagnosis of ectopic pregnancy.

Chorionic Gonadotropin↗
PubMed1991

Immunohistological demonstration of intermediate trophoblast in the diagnosis of uterine versus ectopic pregnancy: a retrospective survey and results of a prospective trial.

Immunohistological demonstration of human placental lactogen (hPL) in non-villous, mononuclear intermediate trophoblastic cells may be of routine diagnostic value, when chorionic villi are absent in endometrial curettings from patients suspected of miscarriage of an intrauterine pregnancy. The histological presence and distribution of hPL was investigated in endometrial curettings from 90 patients studied retrospectively (47 had ectopic pregnancies, 14 miscarriages, and 29 legal abortions), and a consecutive, prospective series of 50 patients (40 had miscarriages and 10 had ectopic pregnancies) without chorionic villi in their endometrial curettings. Non-specific background staining was not a problem. The retrospective survey disclosed that hPL was a highly sensitive marker of intrauterine pregnancy (sensitivity = 0.98). In the prospective series, the predictive value of positive staining for hPL for intrauterine pregnancy was 1.00, and the sensitivity of hPL, as an indicator of uterine gestation, was 0.62. In absence of specific hPL-staining, the risk of ectopic pregnancy was about 50%. The immunohistochemical demonstration of hPL is a useful tool for identifying patients who are suspected of having had a miscarriage, but for whom evidence in the form of chorionic villi in endometrial curettings is lacking.

Abortion, Spontaneous↗
PubMed1994

Circulating levels of placental protein 14 in ectopic pregnancy.

OBJECTIVE: To determine circulating levels of placental protein 14 (PP14) in complications of early pregnancy. DESIGN: Biochemical monitoring of women presenting with vaginal bleeding and/or abdominal pain. SETTING: An emergency gynaecological ultrasound clinic in a London teaching hospital. SUBJECTS: Venous blood samples were obtained from 67 women with normal pregnancy (n = 9), ectopic pregnancy (n = 26) and failed intrauterine pregnancy (n = 32). This group included anembryonic pregnancy (n = 18), missed miscarriage (n = 2), spontaneous miscarriage of a previously demonstrated live fetus (n = 6), incomplete miscarriage (n = 4), complete miscarriage (n = 1) and molar pregnancy (n = 1). MAIN OUTCOME MEASURES: Serum PP14 levels in the group of women with a failed intrauterine pregnancy in relation to the normal range for PP14. RESULTS: Eighty-one percent of women who miscarried spontaneously had normal serum PP14 levels; 81% of women with ectopic pregnancy had depressed (< 5th centile) serum PP14 levels. CONCLUSION: Measurements of PP14 may be useful in distinguishing spontaneous miscarriage from ectopic pregnancy, but not in the management of threatened miscarriage.

Abdominal Pain↗
PubMed1996

Persistent ectopic pregnancy following conservative surgery for tubal pregnancy.

OBJECTIVE: To audit the incidence and management of persistent ectopic pregnancy following conservative tubal surgery performed at laparotomy and via the laparoscope. DESIGN: A retrospective analysis of the case records. SETTING: The Birmingham and Midland Hospital for Women. PARTICIPANTS: Two hundred and fourteen women who received surgical treatment for ectopic pregnancy between October 1991 and December 1994. RESULTS: Of the 85 women who underwent conservative tubal surgery, nine were diagnosed as having persistent ectopic pregnancy on the basis of hCG values. The incidence after laparoscopy was no higher than after laparotomy. A second surgical procedure was indicated in only four cases. CONCLUSIONS: Post-operative surveillance of serum hCG remains mandatory. Patients who remain symptom free may be managed conservatively The threshold for a second-look laparoscopy should be relatively high and be based on the presence of symptoms rather than changes in hCG values.

Chorionic Gonadotropin↗
PubMed2000

Trends in the incidence of ectopic pregnancy in England and Wales from 1966 to 1996.

OBJECTIVE: To examine the incidence of ectopic pregnancy over the period 1966 to 1996. SETTING: England and Wales. DESIGN: Use of official statistics on hospital discharges, maternities, legal abortions and estimated populations of women aged 15-44 years. MAIN OUTCOME MEASURES: Incidence rates of ectopic pregnancies. RESULTS: Between 1966 to 1970 and 1994 to 1996 the recorded incidence increased 4.5-fold from 3.45 to 15.5 per 1000 maternities, 3.8-fold from 3.25 to 12.4 per 1000 pregnancies and 3.1-fold from 30.2 to 94.8 per 100,000 women aged 15-44. The rate of increase was not uniform. Incidence approximately doubled between 1966 and 1985, when the official data collection system changed. By 1989, when data from the new system became available, there had been a further almost doubling of recorded incidence. Subsequently, the upward trend appears to have continued until 1991 to 1992 and has remained stable in the last four years of the study. The trends were similar in each of three 10-year age groups. CONCLUSIONS: The recorded incidence of ectopic pregnancy has increased markedly over the last three decades. This may be partly due to artefacts of data recording and more sensitive diagnostic tests, but it is likely that the actual incidence has increased, probably due to a sexually transmitted agent.

Adolescent↗