Role of sonography in the diagnosis of ectopic pregnancy

Use of Magnetic Resonance Imaging (MRI) in the Management of Diagnostic Uncertainty in Low-Resource Settings: A Case Report of Cesarean Ectopic Pregnancy in a Tertiary Hospital in Ghana

Patient: Female, 35-year-old

Final Diagnosis: Cesarean section ectopic pregnancy

Symptoms: Amenorrhea

Medication:—

Clinical Procedure: Exploratory laparotomy • MRI • ultrasonography

Specialty: Obstetrics and Gynecology

Ultrasound Measured Depth of Pelvic Free Fluid Correlates Well with Blood Loss Volume in Patients with Ectopic Pregnancy

Purpose

The ultrasonic finding of pelvic free fluid which suggests the possibility of internal haemorrhage helps the determination of the severity of patients.

Methods

We conducted a retrospective study investigating ultrasonic measurements and haemorrhage volumes in patients having an ectopic pregnancy in a single centre from January 2013 to November 2016. The logistic regression model was used to establish the prediction model for haemorrhage volumes. The diagnostic accuracy was evaluated by area under ROC curve (AUC) analysis. We employed 800 ml as the cut-off point of the haemorrhage and further set it to 1000 ml and 1200 ml in the sensitivity analysis.

Results

The mean pelvic free fluid depths measured by TVS and TAS were 4.45 ± 2.15 cm and 4.45 ± 2.56 cm in the haemorrhage ≥800 ml group, while they were 2.48 ± 1.51 cm and 2.55 ± 1.19 cm in <800 ml group. AUCs and the corresponding cut-off points were 0.741 (95% CI 0.677 to 0.804) and 0.118 when predicted by the standardised depths of TVS and TAS, 0.784 (95% CI 0.696–0.872) and 2.95 cm by the raw depths of TVS, and 0.748 (95% CI 0.665–0.831) and 3.35 cm by the raw depths of TAS.

Conclusions

The depth of pelvic free fluid measured by TVS and TAS can be used to predict blood loss volume in patients having an ectopic pregnancy. TVS may perform better than TAS.

Cesarean Scar - Unusual Site of Ectopic Pregnancy: A Case Report

Ectopic pregnancy is a leading cause of maternal mortality in the first trimester. It may occur in different anatomic locations with fallopian tube being the most frequent. Cesarean-scar ectopic pregnancy is one of the rarest ectopic pregnancies. We report the case of a 44-year-old woman, gravida 5 para 4, who attended the antenatal clinic after her pregnancy was confirmed by positive urine testing. She underwent transvaginal ultrasound examination which identified the gestational sac with fetal pole and cardiac activity located in the anterior part of the lower uterine segment with empty uterine cavity. Magnetic resonance imaging (MRI) scan had confirmed the diagnosis of cesarean scar ectopic pregnancy. After through discussion on the management options, the patient was treated with intra-gestational sac injection of methotrexate. Four days after the procedure, she developed profuse vaginal bleeding and her hemoglobin showed a drop of 4.9 g/dL. She underwent emergency laparotomy with excision of the ectopic pregnancy. The patient tolerated the procedure well without complications. The serum β-human chorionic gonadotropin level was undetectable on the 35^th day after the methotrexate injection. Caesarean scar pregnancy is an unusual form of ectopic pregnancy. However, clinicians should have a high index of suspicion for this condition as it may result in serious complications, unless promptly managed. MRI is recommended particularly when transvaginal ultrasound scan is inconclusive.

The diagnostic role of the β-hCG discriminatory zone combined with the endometrial pattern for ectopic pregnancy in Chinese women

Previous studies have regarded the discriminatory serum β-hCG zone (DSZ) as a valuable tool for the diagnosis of ectopic pregnancy (EP). However, the wide range of the DSZ makes achieving a clinical diagnosis of EP difficult, and these reports do not indicate whether the DSZ is suitable for an EP diagnosis in Chinese women. Several studies have indicated that the endometrial pattern in patients with EPs is different from that in patients with intrauterine pregnancies (IUPs). The aims of this study were to define the DSZ cutoff value for Chinese women, test whether the endometrial pattern is a suitable predictor for EP, and assess the diagnostic value of these indicators. We enrolled participants with IUPs or EPs with abdominal pain and/or vaginal bleeding, and serum β-hCG level measurements and transvaginal ultrasound (TVS) were performed to assess the diagnostic value of the indicators for EP. The sensitivity and specificity for identifying an EP were improved by combining the DSZ, endometrial thickness and trilaminar pattern indexes. The results of this study might be helpful toward providing further options for the diagnosis of EP, especially for patients without hemoperitoneum or colporrhagia.

Caesarean scar pregnancy in the UK: a national cohort study

OBJECTIVE

To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition.

DESIGN

A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS).

SETTING

86 participating Early Pregnancy Units.

POPULATION

All women diagnosed in the participating units with CSP between November 2013 and January 2015.

METHODS

Cohort study of women identified through the UKEPSS monthly mailing system.

MAIN OUTCOME MEASURES

Incidence, clinical outcomes and complications.

RESULTS

102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management.

CONCLUSIONS

Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up.

TWEETABLE ABSTRACT

Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.