Laparoscopic sterilization

Laparoscopic female sterilization is still the leading method of family planning for patients who have completed their family. Mechanical methods include clips and rings and are preferred because they are safe and efficient and can be used on a day case basis. Appropriate training ensures improved results with fewer complications. Clips and rings have an improved reversal potential.

A systematic review of single-dose intramuscular methotrexate for the treatment of ectopic pregnancy

The use of single-dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side-effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side-effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single-dose intramuscular methotrexate is associated with a high failure rate. Follow-up is prolonged and there is a significant incidence of minor side-effects. Serious complications and side-effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.

[Incidence and mortality of extrauterine pregnancy in Hungary (1931-1995)]

The authors report on the changing incidence of and maternal mortality from ectopic pregnancies in Hungary between 1931 and 1995. Data of reported pregnancies were obtained from the National Institute of Statistics and the Hungarian College of Obstetricians and Gynecologists. Incidence of ectopic pregnancy was calculated as rates per 1000 live births and per 1000 reported pregnancies including live births, legally induced abortions, miscarriages, and ectopic pregnancies. Ectopic pregnancy-associated maternal mortality was examined in terms of case fatality rate and also as a proportion to the total number of pregnancy-associated maternal deaths. From 1931, when national surveillance for pregnancy begun in Hungary, to 1995, the rate per 1000 reported live births tripled from 3.4 to 11.9. Similarly, the rate of ectopic pregnancies per 1000 reported pregnancies increased by 190% from 3.7 to 6.4. In the last decade of the period studied, its proportion in the annual number of fetal deaths increased to 8.0%. Ectopic pregnancy-associated maternal deaths decreased sharply from 1931 through the late 1980's. In the last decade, its average value was 16 per 10.000 reported ectopic pregnancies. However, case fatality rate of ectopic pregnancy is still highest compared to any of the other obstetric events including induced and spontaneous abortions, and deliveries. Over the last decade, maternal deaths resulting from ectopic gestation represented 8.7% of the total maternal mortality rate. Given the increasing incidence of ectopic pregnancy together with a substantial proportion in pregnancy-related maternal mortality, study of etiology, and appropriate preventive measures are urgently needed.

[Intervention approach and its effect on lowering mortality of ectopic pregnancy in Shanghai]

OBJECTIVE

To explore an effective intervention approach to lower the mortality of ectopic pregnancy.

METHODS

We monitored the mortality of ectopic pregnancy during 1987-1995 in Shanghai and experts' audit, focusing on the causes of death from ectopic pregnancy and combining official administration with intervention approach in medical institutions.

RESULTS

Misdiagnosis and patient's delay to hospital were the causes of death from ectopic pregnancy. There were 523,299 live births in Shanghai from 1987 to 1989, in which 23 cases died from ectopic pregnancy, with a mortality of 4.40/100,000. After implementing the intervention approach, during 1990-1995, 14 cases of the total 625,206 nancies live birth died from ectopic pregnancy, with a mortality of 2.24/100,000, as compared the two, P < 0.05. Accordingly, ectopic pregnancy as the cause of maternal death dropped from the first leading cause to the fourth.

CONCLUSION

Intensive health care education in masses, medical staffs' awareness to ectopic pregnancy, and intervention, early hospitalization, early diagnosis and early therapy can lower the mortality of ectopic pregnancy.

[Ectopic pregnancy. The "epidemic" seems to be over]

Since decades the incidence of ectopic pregnancy has risen in most western countries including four to five folded increased rates, suggesting an "epidemic". Increasing incidences of ectopic pregnancy was reported in Sweden until 1988 and 1989 when a peak of 17.3 cases of ectopic pregnancy/10,000 women in fertile age was registered. Between 1990 and 1991 the incidence decreased from 16.8 to 14.9 cases of ectopic pregnancy/10,000 women. The mortality in Sweden 1985-1991 was 0.15/1000 (3 deaths in 20,486 cases of ectopic pregnancy), the lowest case-fatality rate ever reported.

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.

Decrease in the rate of ruptured ectopic pregnancies: a successful team approach

Noting the increasing frequency of ectopic pregnancy and desiring to reduce both morbidity and mortality, OB/GYN physicians at a large midwestern HMO systematically monitored all ectopic pregnancies in their clinical practice as the first step in a quality improvement project. Data were collected on several components of care including access, risk assessment, diagnosis of ectopic pregnancy, and intervention. To ensure the system was able to coordinate new diagnostic and therapeutic modalities, several key initiatives were instituted to improve patient outcomes. These included application of comprehensive guidelines, increased ultrasound availability, and increased staff and patient awareness. Following the implementation of the initiatives, there was a decrease in rupture rates from 32% in 1988 to 5% in 1992. This paper discusses the development and integration of the initiatives into the staff model HMO.

Surveillance for ectopic pregnancy--United States, 1970-1989

PROBLEM/CONDITION

From 1970 through 1989, hospitalizations for ectopic pregnancy have increased in the United States; the number of cases has increased fivefold, from 17,800 to 88,400.

REPORTING PERIOD COVERED

1970-1989.

DESCRIPTION OF SYSTEM

Reported ectopic pregnancies were estimated from data collected by CDC's National Center for Health Statistics (NCHS) as part of the ongoing National Hospital Discharge Survey. Data from responding hospitals were weighted to represent national estimates. The number of deaths resulting from ectopic pregnancy was based on U.S. vital statistics collected by NCHS. Denominators for calculating ectopic pregnancy rates were the total number of reported pregnancies, which includes live births, legal induced abortions, and ectopic pregnancies. Data for live births were obtained from NCHS natality statistics and data for legal induced abortions from CDC's Division of Reproductive Health.

RESULTS

From 1970 through 1989, more than one million ectopic pregnancies were estimated to have occurred among women in the United States; the rate increased by almost fourfold, from 4.5 to 16.0 ectopic pregnancies per 1,000 reported pregnancies. Although ectopic pregnancies accounted for < 2% of all reported pregnancies during this period, complications of this condition were associated with approximately 13% of all pregnancy-related deaths. During this period, the risk of death associated with ectopic pregnancy decreased by 90%: the case-fatality rate declined from 35.5 deaths per 10,000 ectopic pregnancies in 1970 to 3.8 in 1989. The risks of ectopic pregnancy and death from its complications were consistently higher for blacks and other racial/ethnic minorities than for whites throughout the period.

INTERPRETATION

Although the general trend has been for the numbers and rates of ectopic pregnancy to increase over the 20-year period, the variability of the data does not permit meaningful conclusions to be made about year-to-year changes in the estimates of ectopic pregnancies, especially for the years 1988 and 1989.

ACTIONS TAKEN

These findings indicate the need to characterize behaviors and risk factors that may respond to preventive interventions. Until these risks factors are better characterized, early detection and appropriate management of ectopic pregnancies will remain the most effective means of reducing the morbidity and mortality associated with this condition.

Ectopic pregnancy--United States, 1988-1989

Although the number and rate of ectopic pregnancies in the United States increased from 1970 through 1987, they stabilized from 1987 through 1989 (1). This report presents data regarding the number and rate of ectopic pregnancies and ectopic pregnancy-related deaths in the United States from 1988 through 1989 and compares those data with information reported since 1970.

Ectopic pregnancy

The incidence of ectopic pregnancy has been increasing for many years and currently is two to three times higher than it was 20 or 25 years ago. The reasons for this are complex and include increased rates of pelvic and tubal infection, the use of the IUD, surgery in the pelvis for infertility, sterilization and other surgical procedures, in vitro fertilization, and improved diagnosis. Normal tubal physiology, the findings in affected tubes, and the mechanisms of how the ectopic pregnancy develops and involves the tube are considered. The cardinal points of the history and physical examination are presented in considerable detail. Further, the evolution of the tools of diagnosis--curettage, culdocentesis, laparotomy, laparoscopy, hormonal tests, and ultrasound-is considered. The different approaches to therapy are presented. Salpingectomy was once the method of accepted therapy, but currently conservative management (salpingostomy) is the most acceptable approach. More recently, selected patients are being treated with observation and a small subgroup are being managed with methotrexate and other chemical agents injected directly into the ectopic pregnancy. Ectopic pregnancy is still a leading cause of maternal death despite improved diagnosis and therapy. It should be remembered, however, that the total number of women who die from this condition is less than ever before and this is despite the rising incidence of ectopic pregnancy. There is still much to be learned about ectopic pregnancy, its etiology, diagnosis, and management.

Ectopic pregnancy surveillance, United States, 1970-1987

In 1987, both the rate of hospitalizations due to ectopic pregnancy and the number of women hospitalized increased from those reported in 1986. Although ectopic pregnancy represented 1.7% of all pregnancies in 1987, complications of this condition accounted for 12% of all maternal deaths in that year. The case-fatality rate was 3.4 deaths per 10,000 ectopic pregnancies, a decline of 30% from the rate of 4.9 deaths reported in 1986, and a 90% decline from the 35.5 deaths per 10,000 ectopic pregnancies reported in 1970. Although the racial gap decreased slightly in 1987, the risk of ectopic pregnancy remained 1.4 times higher for women of black and other minority races than for white women. The risk of death from this condition remained 1.8 times higher for women of black and other minority races.

Ectopic pregnancy concurrent with induced abortion: incidence and mortality

From 1972 through 1985, 24 women who underwent an induced abortion died as a result of a concurrent ectopic pregnancy. We analyzed data from the Joint Program for the Study of Abortion, National Hospital Discharge Survey, and the Centers for Disease Control Ectopic Pregnancy and Abortion Surveillance Systems to determine the incidence and mortality of ectopic pregnancy concurrent with induced abortion. During the period 1971 through 1985, the incidence of ectopic pregnancy concurrent with induced abortions was 1.35/1000 induced abortions, compared with 13.6/1000 pregnancies not terminated by induced or spontaneous abortion. The rate was higher among women who obtained abortions at earlier gestational age and among older women. The death-to-case rate for ectopic pregnancies concurrent with induced abortion was 1.3 times higher than that for women not undergoing abortion. Most of the deaths of women with ectopic pregnancy who underwent induced abortion were attributable to the failure to diagnose the ectopic pregnancy before the woman left the facility where the abortion was performed. Such deaths could be prevented by the provider of the abortion assuring that the tissue is examined for products of conception at the time of the abortion.

Ectopic pregnancy in the United States, 1970-1986

In 1986, both the rate of hospitalizations due to ectopic pregnancy and the number of hospitalizations decreased from those reported in the previous year, although the decreases were not statistically significant. If this leveling off of previous yearly increases becomes a continuing trend, possible explanatory hypotheses include a leveling off of disease occurrence, and an increasing use of outpatient management. The case-fatality rate rose slightly in 1986, to 4.9 deaths per 10,000 ectopic pregnancies, although this rate still represents an 86% decline from the 35.5 deaths per 10,000 ectopic pregnancies reported in 1970. In 1986, ectopic pregnancy accounted for only 1.4% of all pregnancies but was associated with over 13% of maternal deaths. Compared with white women, women of black and other minority races had a 1.6 times greater risk of ectopic pregnancy. Ectopic pregnancy remains one of the leading causes of maternal death in the United States and continues to be an important public health problem.

Maternal mortality in Hong Kong 1961-1985

The maternal mortality rate in Hong Kong fell from 0.45/1000 total births in 1961 to 0.05/1000 total births in 1985. During the period between 1961 and 1985 there were a total of 438 maternal deaths and 2,193,012 births. Of the 438 deaths 150 (34%) were due to haemorrhage during pregnancy and childbirth (ICD 640, 641, 666), 89 (20%) were due to pre-eclampsia (ICD 642, 643) and 60 (13.7%) were due to ectopic pregnancy (ICD 633). Comparison of maternal deaths by cause between the periods 1961-1965 and 1981-1985 showed an 86% reduction in deaths due to haemorrhage and pre-eclampsia and a 72% reduction in deaths due to ectopic pregnancy. Pulmonary embolism was not a major cause of maternal mortality.

Ectopic pregnancy surveillance, United States, 1970-1985

Ectopic pregnancy is now one of the leading causes of maternal death in the United States. In 1984 and 1985, both the numbers and rates of ectopic pregnancy increased. Since the rate of ectopic pregnancy remained unchanged for white women, the rate increase appears to be driven by the increasing rate among women of black and other races. Although ectopic pregnancies accounted for only 1.5% of the total pregnancies in 1984 and 1985, they accounted for 14% of the total maternal deaths in 1984 and for 11% of those deaths in 1985. However, the case-fatality rate for 1985 decreased to 4.2/10,000 ectopic pregnancies, down from the 35.5 deaths/10,000 ectopic pregnancies reported in 1970. Several factors may contribute to the increase in ectopic pregnancies, including heightened awareness of the condition, improved diagnostic technology, and possibly the higher prevalence of risk factors (e.g., acute and chronic salpingitis and sexually transmitted diseases) and the lower prevalence of protective factors (e.g., decreased use of oral contraceptives). Heightened awareness of the condition and improved technology may also be factors resulting in the decreased case-fatality rate.