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PubMed2001

An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy.

OBJECTIVE: To compare the direct and indirect costs of single dose systemic methotrexate with laparoscopic surgery for the treatment of unruptured ectopic pregnancy. DESIGN: A cost minimisation study undertaken alongside a randomised trial. SETTING: Departments of Obstetrics and Gynaecology in three hospitals in Auckland, New Zealand. PARTICIPANTS: Sixty-two women with an ectopic pregnancy randomised to treatment with either a single dose of methotrexate (50 mg/m2) or laparoscopic surgery. MAIN OUTCOME MEASURES: Direct and indirect costs based on the results of the randomised trial. RESULTS: Direct costs per case were significantly lower in the methotrexate group (mean $NZ 1,470) than in the laparoscopy group (mean $NZ 3,083) with a mean difference of $NZ 1,613 (95% CI $NZ 1,166 - $NZ 2,061). These significant differences existed under a wide range of alternative assumptions about unit costs. The difference in direct costs in favour of methotrexate was greatest for women presenting with low pretreatment serum beta-hCG concentrations. Mean indirect costs were also significantly lower in the methotrexate group (mean $NZ 1,141) than in the laparoscopy group (mean $NZ 1899) with a mean difference of $NZ 758 (95% CI $NZ 277 - $NZ 1,240). For women presenting with pretreatment serum beta-hCG concentrations of over 1,500 IU/ L this difference in indirect costs is lost due to the prolonged follow up required and a higher rate of surgical intervention in women receiving methotrexate. CONCLUSION: This economic evaluation shows that treating suitable women with an ectopic pregnancy using systemic methotrexate therapy results in a significant reduction in direct costs. The indirect costs borne by the woman and her carers are only likely to be reduced in women with pretreatment serum beta-hCG concentrations under 1,500 IU/L.

Abortifacient Agents, Nonsteroidal↗
PubMed1983

A prospective study of beta HCG radioimmunoassay in the diagnosis of ectopic and other complicated early pregnancies.

The beta-subunit of chorionic gonadotrophin (beta HCG) was measured by radioimmunoassay in the serum of 190 consecutive patients admitted to hospital with the suspicion of ectopic pregnancy. The detection limit was set at 1 ng/ml. A urine sample was also taken for pregnancy testing on admission. A positive serum beta HCG result was obtained in 36 patients (19%); pregnancy was confirmed in 32 (ectopic pregnancy 14, abortion 8, continuing normal pregnancy 7, retained products 3), giving a predictive value of 89%. There was poor correlation between serum and urine results. The serum levels were low in patients who subsequently aborted, intermediate in those with ectopic pregnancy and within the normal range in patients in whom the pregnancy continued normally. The high predictive value of the test should identify the patients for further investigation, thus avoiding unnecessary operative procedures and prolonged hospital stay.

Abortion, Incomplete↗
PubMed1997

Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy?

There is a widespread belief that salpingostomy is the treatment of choice for ectopic pregnancy. The ability to treat most ectopic pregnancies via a laparoscopic approach has been a major advance in gynaecological surgery. Despite the well publicized benefits of laparoscopy over laparotomy only 50% of patients with ectopic pregnancies in Australia presently benefit from this surgical advance. Although it is clear that laparoscopic treatments are preferable to laparotomy there is no consensus on whether salpingectomy or salpingostomy should be performed, despite over 40 years of research since the introduction of conservative tubal treatment. A systematic review of laparoscopic surgical treatment is needed and could be incorporated into the Cochrane Collaboration. A prospective clinical study, with long-term follow-up, needs to be performed to evaluate fertility prognosis and complications after laparoscopic salpingectomy versus salpingostomy.

Female↗
PubMed2001

Trends in the incidence of ectopic pregnancy in New South Wales between 1990-1998.

During the last three decades, ectopic pregnancy rates have increased considerably in different parts of the world including Australia. Recent reports, however, suggest that the incidence is decreasing or at least stabilising. An analysis of the New South Wales Inpatient Statistics Data collected during the period between 1990 and 1998 has shown a decline in the rate of ectopic pregnancy after 1993. Overall the rate decreased from 17.4 per 1,000 births in 1990-1991 to 16.2 per 1,000 births in 1997-1998. The decline was greater for women aged 35-44 years than for younger women. The findings are consistent with recent studies in other countries, which indicate slowing or the end of the previous upward trend in the incidence of ectopic pregnancy

Adolescent↗
PubMed1997

Three-dimensional electromagnetic catheter technology: electroanatomical mapping of the right atrium and ablation of ectopic atrial tachycardia.

INTRODUCTION: The difficult catheter orientation and navigation associated with conventional technology and mono-/multiplane fluoroscopy may complicate ablation procedures of atrial tachycardias. A new three-dimensional catheter technology for electroanatomical mapping of the right atrium and ablation of ectopic atrial tachycardia is described. METHODS AND RESULTS: A novel electromagnetic catheter-based mapping system was investigated for electroanatomical mapping of the entire right atrium in 12 patients. The system reconstructed three-dimensional maps from the multitude of endocardial sites that were sequentially mapped and color coded the individual activation times. The electrophysiologic information was superimposed on the geometry of the mapped area. The anatomical landmarks of the right atrium, i.e., the tricuspid annulus, mouth of the coronary sinus, ostia of the superior and inferior venae cavae, and right atrial appendage, could be depicted in all cases. The sinus node area and the preferential conduction along the crista terminalis could be delineated. In four patients with ectopic atrial tachycardia, the earliest endocardial activation could be identified with high spatial resolution as a "hot spot." After completion of the mapping procedure, the ablation catheter could be reliably renavigated to the site of origin, and ablation was successful with one or two impulses. In one patient with previous atrial septal repair, the activation map allowed the reconstruction of a long line of conduction block induced by the atriotomy. CONCLUSION: Three-dimensional electroanatomical mapping of the right atrium allowed detailed reconstruction of the chamber geometry and activation sequence. The sites of origin of ectopic atrial tachycardias could be identified precisely. The system allowed accurate renavigation to the site of earliest activation, thereby guiding successful ablation of the foci.

Adult↗
PubMed1995

Transcatheter ablation of incessant ectopic left atrial tachycardia using radiofrequency current.

Catheter ablation of ectopic atrial tachycardia has been previously reported in a small number of patients in whom the ectopic focus was predominantly located in the right atrium. We report on a 51-year-old patient with atrial automatic tachycardia originating in the left atrium, in whom successful radiofrequency catheter ablation was performed via a transseptal puncture. The patient had suffered incessant atrial tachycardia for several years, refractory to antiarrhythmic drug treatment and DC-cardioversion. Radiofrequency ablation terminated left ectopic atrial tachycardia and, therefore, should have been attempted before resorting to open heart surgical ablation.

Catheter Ablation↗
PubMedDate not supplied

Ectopic pregnancy: a nursing approach to excess risk among minority women.

Ectopic pregnancy rates have quadrupled during the last decade. Although maternal mortality has been reduced for white women, largely because of rapid pregnancy testing and improved ultrasonography, the death rate for minority women is almost twice that of white women, and minority adolescents are almost five times as likely to die of ectopic pregnancy. In this article, causative factors are identified, and the potential for race, gender, and age bias in diagnosis and treatment is discussed. Involvement by nurses in preventive programs, clinical research, and advocacy for policy change may help reduce ectopic pregnancy mortality rates.

Adolescent↗
PubMed1995

Ectopic pregnancy--Part II: Diagnostic procedures and imaging.

Ectopic pregnancy is an increasingly common and potentially catastrophic condition in which the patient often presents to the ED with abdominal pain or vaginal bleeding. Recent developments in the laboratory (sensitive beta hCG assays, progesterone assays), in ultrasonography (transvaginal probes, Doppler ultrasonography), and in the combination of modalities (discriminatory zone of beta hCG for ultrasonographic evidence of IUP) have allowed the earlier diagnosis of ectopic pregnancy, with the potential for a reduction in maternal mortality and morbidity. Understanding the strengths and limitations of the variety of diagnostic modalities available will allow the clinician to formulate a rational strategy for the early diagnosis of ectopic pregnancy. Numerous algorithms have been developed. All begin with high clinical suspicion for women of reproductive age with abdominal/pelvic pain or vaginal bleeding. Pregnancy testing with a sensitive beta hCG qualitative test is next. For stable patients found to be pregnant, sonography generally follows (often first transabdominally then transvaginally). Unstable patients require immediate resuscitation and gynecology consultation; invasive diagnostic methods may supplant laboratory studies and sonography. Unclear cases may necessitate the use of quantitative beta hCG (discriminatory zone), other pregnancy hormones (progesterone), invasive procedures (laparoscopy, culdocentesis, D&C), or observation (serial beta hCGs). A suggested algorithm incorporating these elements is shown (Fig. 1).

Algorithms↗
PubMed2025

Ectopic recombination: a novel mechanism of EPSPS gene amplification in glyphosate-resistant Chloris truncata.

Amplification of 5-enolpyruvylshikimate-3-P synthase (EPSPS) gene confers resistance to the herbicide glyphosate in the tetraploid Chloris truncata in Australia. To study the mechanism of amplification, the genomic organization of the EPSPS gene was investigated using fluorescence in situ hybridization (FISH) in one susceptible (Ct-S) and two resistant (Ct-R1 and Ct-R2) biotypes of C. truncata. FISH analysis revealed faint signals of the EPSPS gene on the telomeric regions of a single pair of homologous chromosomes in Ct-S plants. However, much brighter hybridization signals of the EPSPS gene were detected on three pairs of homologous chromosomes in Ct-R1 and on four pairs in the Ct-R2 plants. Thus, there was gene amplification on the native EPSPS locus as well as spread of EPSPS loci to additional chromosomes. All loci were detected in terminal regions which are hotspots of recombination. This local as well as ectopic EPSPS amplification to specific regions of chromosomes is a novel mechanism resistance to herbicides. We hypothesize that, during the bouquet stage of meiosis, telomeres come together forming a bouquet and this may provide an opportunity for ectopic recombination, supported by FISH analyses in interphase nuclei. Overall, the gene amplification appears to have occurred in two steps. First, there was tandem EPSPS amplification at the native locus, possibly via unequal recombination. Second, the amplified locus underwent ectopic recombination and spread to two additional chromosomes in Ct-R1 and three additional chromosomes in Ct-R2 plants.

Glyphosate↗
PubMed1970

Place of culdocentesis in the diagnosis of ectopic pregnancy.

In developing countries the high incidence of anaemia and pelvic infection often makes the diagnosis of ectopic pregnancy difficult. Culdocentesis has been used in 100 doubtful cases out of 144 consecutive cases of ectopic pregnancy. The preoperative diagnosis was correct in 93 out of the 100 cases. There were three false-negative and four false-positive results; only two unnecessary laparotomies were performed. It is suggested that culdocentesis has an essential place in the early diagnosis of doubtful or atypical ectopic pregnancy. It was simple, safe, and reliable. Owing to earlier diagnosis maternal mortality and morbidity and the duration of stay in hospital have all been reduced.

Adult↗
PubMed1998

Ectopic pregnancy presenting with obturator nerve pain.

A 27 year old woman had a three day history of pain in the cutaneous distribution of the left obturator nerve before she developed the classical picture of ectopic pregnancy with lower abdominal pain and vaginal bleeding. A left tubal pregnancy was subsequently confirmed by laparoscopy. Referred pain along the obturator nerve has been reported in other pelvic conditions, but has not previously been reported as a manifestation of ectopic pregnancy. Ectopic pregnancy may present with a very wide range of signs and symptoms and should be excluded in females of child bearing age with unexplained symptoms including pain anywhere from the shoulder down to the knee.

Adult↗
PubMed1983

Ultrasonographic differentiation of the gestational sac of early intrauterine pregnancy from the pseudogestational sac of ectopic pregnancy.

A retrospective review of 128 consecutively scanned pregnant patients who had either early intrauterine pregnancies (IUPs) or ectopic pregnancies was performed to determine the accuracy of the finding of an intrauterine double decidual sac (DDS) in distinguishing between these two groups of patients. The presence of a DDS correlated with an IUP in 59 of 60 patients (98.3%). Of 68 patients who lacked a DDS, only four had normal IUPs; the remaining patients had either ectopic pregnancies or abnormal IUPs. Results of this study suggest that the finding of a DDS at ultrasonography is useful in making an early diagnosis of IUP, while its absence strongly suggests either an ectopic pregnancy or an abnormal IUP.

Decidua↗
PubMed1984

Coexistent intrauterine and ectopic pregnancy: a reevaluation.

Retrospective analysis of ectopic pregnancies occurring in the past 36 months at the Beth Israel Hospital yielded two cases of concomitant intra- and extrauterine gestation. The incidence of coexistent intrauterine and ectopic pregnancy in this sample is 1/6,778, or 0.015% of all pregnancies. We report these cases and two additional cases from another institution (Leonard Morse Hospital). We postulate that simultaneous intrauterine and ectopic pregnancy may be more common than previous statistics indicate.

Adult↗
PubMed1992

Diagnostic efficacy of endovaginal color Doppler flow imaging in an ectopic pregnancy screening program.

The authors compared the diagnostic yield of endovaginal color and pulsed Doppler ultrasound (US) in conjunction with endovaginal sonography with that of endovaginal sonography alone in patients prescreened to be at increased risk for ectopic pregnancy. Pelvic structures were evaluated for overall vascularity and for the presence of characteristic pulsed Doppler US velocity waveforms. The diagnostic sensitivity of the initial endovaginal sonographic examination increased with the addition of color and pulsed Doppler US, from 71% to 87% for ectopic pregnancy, from 24% to 59% for failed intrauterine pregnancy, and from 90% to 99% for viable intrauterine pregnancy. Specificities for endovaginal sonography with color and pulsed Doppler US ranged from 99% to 100%. Use of endovaginal color and pulsed Doppler US increased the percentage of diagnostic initial sonographic examinations from 62% to 82%. The improved diagnostic sensitivity of endovaginal color Doppler US for ectopic pregnancy may ultimately result in earlier treatment, with reduced morbidity and mortality.

Color↗
PubMed1993

Pelvic MR imaging findings in gestational trophoblastic disease, incomplete abortion, and ectopic pregnancy: are they specific?

Thirty-nine patients with abnormally elevated levels of serum beta subunit of human chorionic gonadotropin (beta-hCG) were studied to determine whether findings at magnetic resonance (MR) imaging are specific for primary molar disease, persistent gestational trophoblastic disease (GTD), incomplete abortion, and ectopic pregnancy. Among the latter three groups, the only significant differences were a higher prevalence of endometrial distention in the group with incomplete abortion (P < .0035) and the absence of junctional zone disruption in the group with ectopic pregnancy (P < .05). In the group with primary molar disease, total intrauterine volume was significantly increased (P < .001), and endometrial distention and presence of an endometrial mass had a significantly higher prevalence than that in the persistent GTD groups with (P < .04) or without (P < .001) metastases. Myometrial or extrauterine disease was identified in 65% of the patients with persistent disease and a beta-hCG level greater than 500 mIU/mL (500 IU/L). Thus, although MR imaging findings in persistent GTD, incomplete abortion, and ectopic pregnancy are relatively nonspecific, MR imaging can depict invasive disease that may alter therapeutic management in patients with documented GTD.

Abortion, Incomplete↗
PubMed1994

Cervical ectopic pregnancy: results of conservative treatment.

PURPOSE: To review experience with early sonographic diagnosis and fertility-preserving treatment of cervical ectopic pregnancy. MATERIALS AND METHODS: The authors evaluated 12 consecutive cases of cervical ectopic pregnancy diagnosed with ultrasound (US) and treated with methods that successfully preserved the uterus. Gestational age, sonographic findings, means of conception, and method of treatment were recorded. RESULTS: Gestational age at diagnosis ranged from 5.0 to 7.9 weeks. Cardiac activity was documented in nine cases. Patients were treated as follows: transvaginal US-guided injection of potassium chloride into the embryo or gestational sac (n = 6), uterine artery embolization followed by dilation and evacuation (n = 4), dilation and evacuation after ligation of uterine artery branches (n = 1), and uterine artery embolization followed by administration of systemic methotrexate (n = 1). The cervical pregnancy was successfully ablated with one treatment in all cases. No patient required hysterectomy, and only one patient required transfusion. Two patients subsequently delivered healthy babies; three other patients have been able to conceive successfully. CONCLUSION: When cervical ectopic pregnancy is diagnosed early, US-guided termination or other conservative procedures allow preservation of the uterus, thus maintaining potential fertility.

Cervix Uteri↗
PubMed2006

[Dilated cardiomyopathy secondary to atrial ectopic tachycardia].

Ectopic atrial tachycardia is an uncommon cause of supraventricular tachycardia in children. It can resolve spontaneously or induce dilated cardiomyopathy. It is important to recognize this entity as a reversible cause of dilated cardiomyopathy, characterized by the presence of an abnormal focus located in the atrial myocardium and distinct to sinus node. Treatment strategies include the use of antiarrhythmic drugs, radiofrequency ablation, and, in patients refractory to medical treatment, surgical resection of the ectopic focus. We describe a patient with dilated cardiomyopathy due to an atrial ectopic focus and its resolution after medical treatment.

Cardiomyopathy, Dilated↗
PubMed2000

Could we treat more unruptured ectopic pregnancies with intramuscular methotrexate?

The main reason for the restricted use of methotrexate in the treatment of ectopic pregnancy (EP) obviously is the fear of tubal rupture in patients with lower abdominal pain after the administration of methotrexate. Therefore, we wanted to find out if patient characteristics at first presentation, such as age, pretreatment beta-hCG level, adnexal mass as visualized by transvaginal ultrasonography, or history of prior EP, would identify patients at risk for tubal rupture if they were hemodynamically stable and showed no signs of peritoneal irritation. We examined whether more patients could have been treated medically with methotrexate, because tubal rupture was unforeseeable at first presentation and inclusion criteria for methotrexate treatment were fulfilled. From January 1996 to August 1998, 122 patients diagnosed as having EP were treated at the Gynecologic Department of the University Hospital of Vienna. Inclusion criteria for medical treatment with intramuscular methotrexate (50 mg/ m(2) body surface area) were (1) hemodynamic stability, (2) an unruptured ectopic mass < or = 5 cm at the greatest dimension demonstrated at transvaginal ultrasonography; (3) beta-hCG level < or = 5,000 mIU/ml; (4) no cardiac activity of the extrauterine embryo; (5) wish of future fertility, and (6) informed consent. Patients with hemodynamic instability, severe abdominal pain, an ectopic mass > or = 5 cm at the greatest dimension, beta-hCG levels > or = 5,000 mIU/ml, cardiac activity of the extrauterine embryo, and no wish of future fertility, or disagreement with methotrexate treatment, primarily underwent surgery. Despite the fact that none of the above patient characteristics at first presentation identified patients at risk for tubal rupture, only 60/122 patients (49%) actually underwent medical treatment whereas our inclusion criteria would have granted medical treatment in 101/122 patients (83%). We determined the actual and maximal possible percentages of patients with unruptured EP eligible for medical treatment of EP with intramuscular single-dose methotrexate 50 mg/m(2) body surface area. Our data show that tubal rupture in hemodynamically stable patients is not foreseeable and should not lead to a restricted use of medical treatment in patients preferring methotrexate.

Adult↗