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Jeffers K, Koyfman A, Long B. Updates in emergency medicine: Ectopic pregnancy. Am J Emerg Med 2024; 85:90-97. [PMID: 39244808 DOI: 10.1016/j.ajem.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/24/2024] [Accepted: 09/01/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.
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Affiliation(s)
- Kristine Jeffers
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Cai P, Zheng M, Wang Q, Wen Y, Chen H, Gong F, Lin G, Li X, Ouyang Y. Diagnosis and management of heterotopic intramural pregnancy after in vitro fertilization: an eight-case series. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 39187241 DOI: 10.1055/a-2375-0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/28/2024]
Abstract
PURPOSE To analyze the ultrasound characteristics, clinical management, and pregnancy outcomes of heterotopic intramural pregnancies (HIMPs) after embryo transfer. METHODS This was a retrospective observational study of women who were diagnosed with HIMPs. The ultrasound characteristics, clinical treatment, and pregnancy outcomes of patients with HIMPs were evaluated. RESULTS Eight women with HIMPs were included. Among them, 6 patients were diagnosed by transvaginal sonography, and 2 patients were misdiagnosed with heterotopic interstitial pregnancy. The diagnostic accuracy was 75% (6/8). Five patients with HIMPs were diagnosed at the time of the initial scan (5+6-6+3 weeks). An intramural gestational sac was observed in all 6 patients, and an embryo with cardiac activity was detected in one patient on the follow-up scans. Intrauterine pregnancies (IUPs) were revealed in all 6 patients, and embryo(s) with cardiac activity were observed in 5 patients at the time of the initial diagnosis or later. The patients receiving expectant treatment all presented with bagel signs, while patients with embryos with cardiac activity all underwent surgery. Among the 6 diagnosed women, 1 patient was initially treated medically, 4 were treated expectantly, and 1 was treated surgically. Among the 6 diagnosed patients, the IUPs of 5 patients resulted in live infants. CONCLUSION Single ET should be recommended to decrease the possibility of HIMP. An accurate diagnosis of HIMP was reached in most cases by detailed ultrasound early in the first trimester. Most IUPs of HIMPs seem to have good outcomes with timely and proper management. Expectant management might be a possible choice for nonviable intramural pregnancies.
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Affiliation(s)
- Pei Cai
- Imaging Department, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Mingxiang Zheng
- Imaging Department, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Qian Wang
- Imaging Department, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Yi Wen
- Imaging Department, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Hui Chen
- Endoscope center, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Fei Gong
- Reproductive center, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
- NHC Key Laboratory of Human Stem Cell and Reproductive Engineering, School of Basic Medical Sciences, Central South University, Changsha City, China
| | - Ge Lin
- Reproductive center, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
- NHC Key Laboratory of Human Stem Cell and Reproductive Engineering, School of Basic Medical Sciences, Central South University, Changsha City, China
| | - Xihong Li
- Imaging Department, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Yan Ouyang
- Imaging Department, Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha City, China
- Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
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Hou L, Liang X, Zeng L, Wang Q, Chen Z. Conventional and modern markers of pregnancy of unknown location: Update and narrative review. Int J Gynaecol Obstet 2024. [PMID: 39022869 DOI: 10.1002/ijgo.15807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024]
Abstract
Pregnancy of unknown location (PUL) is a temporary pathologic or physiologic phenomenon of early pregnancy that requires follow up to determine the final pregnancy outcome. Evidence indicated that PUL patients suffer a remarkably higher rate of adverse pregnancy outcomes, represented by ectopic gestation and early pregnancy loss, than the general population. In the past few decades, discussion about PUL has never stopped, and a variety of markers have been widely investigated for the early and accurate evaluation of PUL, including serum biomarkers, ultrasound imaging features, multivariate analysis, and the diagnosis of ectopic pregnancy based on risk stratification. So far, machine learning (ML) methods represented by M4 and M6 logistic regression have gained a level of recognition and are continually improving. Nevertheless, the heterogeneity of PUL markers, mainly caused by the limited sample size, the differences in population and technical maturity, etc., have hampered the management of PUL. With the advancement of multidisciplinary integration and cutting-edge technologies (e.g. artificial intelligence, prediction model development, and telemedicine), novel markers, and strategies for the management of PUL are expected to be developed. In this review, we summarize both conventional and novel markers (represented by artificial intelligence) for PUL assessment and management, investigate their advancements, limitations and challenges, and propose insights on future research direction and clinical application.
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Affiliation(s)
- Likang Hou
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- The First Affiliated Hospital, Medical Imaging Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Xiaowen Liang
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, Department of Medical Imaging, the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
| | - Lingqing Zeng
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- The First Affiliated Hospital, Medical Imaging Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Qian Wang
- The First Affiliated Hospital, Center for Reproductive Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhiyi Chen
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, Department of Medical Imaging, the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
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Mu F, Wang C, Li X, Wang F. The Relationship Between the Average Decreased Times of Estradiol and Early Miscarriage: An Observational Study. Reprod Sci 2024:10.1007/s43032-024-01570-3. [PMID: 38710977 DOI: 10.1007/s43032-024-01570-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/18/2024] [Indexed: 05/08/2024]
Abstract
Decreased estradiol (E2) levels are associated with early miscarriage (EM), but the relationship between decreased times of E2 and EM has not been reported. We aimed to investigate the relationship between the average decreased times of E2 (ADTE) and EM. Women with a history of miscarriage were retrospectively recruited from the Reproductive Center of Lanzhou University Second Hospital (Lanzhou, China) between September 2019 and February 2022. Based on pregnancy outcome, they were divided into ongoing pregnancy group (n = 359) and EM group (n = 104). In addition, subgroup analyses were performed for the number of previous miscarriages and whether E2 levels decreased continuously. The exposure and outcome variables were ADTE and miscarriage before 12 weeks of gestation, respectively. Totally, 1171 patients were recruited and 463 patients were finally analyzed. ADTE was associated with EM (odds ratio [OR] = 1.346, 95% confidence interval [CI]1.154-1.571, P < 0.001). When ADTE ≥ 2.5, the EM risk increased 1.17-fold compared to patients with 0-1.249 times (OR = 2.170, 95% CI 1.144-4.117, P = 0.018). Moreover, a threshold effect existed in the ADTE and the risk of EM with a value of 4.9 times. When exceeding 4.9 times, the EM risk increased 4.713-fold for each increased unit (OR = 5.713, 95% CI 1.255-23.170, P = 0.024). Subgroup analysis showed that ADTE had a greater effect on the occurrence of EM in women with a history of 1-2 miscarriages than in women with 3 miscarriages. Decreased E2 was a risk factor for EM regardless of whether it dropped continuously or not. In conclusion, our study identifies a potential link between ADTE and early miscarriage risk in women with prior miscarriages, yet cautious interpretation is necessary due to inherent design limitations. Further research with prospective designs and large population samples is essential to validate ADTE's utility as a predictive indicator for early miscarriage in clinical settings.
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Affiliation(s)
- Fangxiang Mu
- Department of Reproductive Medicine, Lanzhou University Second Hospital, No. 82 Cuiying Men, Chengguan District, Lanzhou, 730030, Gansu, China
| | - Chen Wang
- Department of Reproductive Medicine, Lanzhou University Second Hospital, No. 82 Cuiying Men, Chengguan District, Lanzhou, 730030, Gansu, China
| | - Xiaofeng Li
- Department of Reproductive Medicine, Lanzhou University Second Hospital, No. 82 Cuiying Men, Chengguan District, Lanzhou, 730030, Gansu, China
| | - Fang Wang
- Department of Reproductive Medicine, Lanzhou University Second Hospital, No. 82 Cuiying Men, Chengguan District, Lanzhou, 730030, Gansu, China.
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Mutiso SK. Correlation of sonographic with intraoperative findings in laparoscopic managed ectopic pregnancies, a 10-year synopsis: a restrospective observational study. BMC Pregnancy Childbirth 2024; 24:296. [PMID: 38643085 PMCID: PMC11032585 DOI: 10.1186/s12884-024-06441-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/24/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Ectopic pregnancies (EP) are a common pregnancy complication that's associated with significant morbidity and rarely mortality if not managed properly. Ultrasound examination forms the cornerstone of diagnosis of EP with some sonographic features occasionally not correlating with intraoperative findings. We set out to conduct an audit of EP managed surgically at our hospital for a 10-year period and discern the correlation and prediction of sonographic findings to intraoperative findings. METHODS This study was designed as a Retrospective Observational Study based at the Aga Khan University Hospital (AKUH). Study population was all women admitted to AKUH with a diagnosis of ectopic pregnancy that was surgically managed between the period of January 1st 2011 to December 31st 2020. Analysis of data was done against a pre-set checklist. Descriptive statistics for continuous variables was calculated and tabulated in graphs and tables. SPSS version 22 was used for analysis of data. RESULTS A total of 337 patients in this study had ultrasound findings. 99.7% (n = 336) of these patients had an intraoperatively confirmed EP. The commonest ultrasound finding was an adnexal mass in 97.1% (n = 309) of patients. These were confirmed surgically in 290 patients at the following locations: 76.6% (n = 222) were ampullary in location; 10.7% (n = 31) were fimbrial in location; 8.6%(n = 25) were isthmic in location; 2.4%(n = 7) were interstitial in location; 1%(n = 3) were abdominal in location; while 0.3% were located in the ovary(n = 1) or round ligament(n = 1) each. Interstitial EP on ultrasound were all (100%) confirmed in the same location intraoperatively, with ampullary EP also correlating fairly well with intraoperative location (75%). The distribution of location in the minor hemoperitoneum (HP) versus major HP groups were similar except for interstitial EP that increased from 1.4% in the minor HP group to 9.5% in the major HP group. CONCLUSION In conclusion, ultrasonography still represents the best imaging modality for EP. The most common finding is usually an adnexal mass with no specific location. Most (99.7%) of the patients with this sonographic finding usually have a confirmed EP. Interstitial EP are the most well localized with ultrasound followed by ampullary EP. Furthermore, the presence of major (> 500mls) hemoperitoneum may act as an adjunct for diagnosis of an interstitial EP.
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Affiliation(s)
- Steve Kyende Mutiso
- Department of Obstetrics and Gynaecology, Aga-Khan University, P.O. Box 30270-00100, Nairobi, Kenya.
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Larraín D, Caradeux J. β-Human Chorionic Gonadotropin Dynamics in Early Gestational Events: A Practical and Updated Reappraisal. Obstet Gynecol Int 2024; 2024:8351132. [PMID: 38486788 PMCID: PMC10940029 DOI: 10.1155/2024/8351132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/06/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the β-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.
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Affiliation(s)
- Demetrio Larraín
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
| | - Javier Caradeux
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
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Kyriacou C, Ledger A, Bobdiwala S, Ayim F, Kirk E, Abughazza O, Guha S, Vathanan V, Gould D, Timmerman D, Van Calster B, Bourne T. Updating M6 pregnancy of unknown location risk-prediction model including evaluation of clinical factors. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:408-418. [PMID: 37842861 DOI: 10.1002/uog.27515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/19/2023] [Accepted: 10/05/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Ectopic pregnancy (EP) is a major high-risk outcome following a pregnancy of unknown location (PUL) classification. Biochemical markers are used to triage PUL as high vs low risk to guide appropriate follow-up. The M6 model is currently the best risk-prediction model. We aimed to update the M6 model and evaluate whether performance can be improved by including clinical factors. METHODS This prospective cohort study recruited consecutive PUL between January 2015 and January 2017 at eight units (Phase 1), with two centers continuing recruitment between January 2017 and March 2021 (Phase 2). Serum samples were collected routinely and sent for β-human chorionic gonadotropin (β-hCG) and progesterone measurement. Clinical factors recorded were maternal age, pain score, bleeding score and history of EP. Based on transvaginal ultrasonography and/or biochemical confirmation during follow-up, PUL were classified subsequently as failed PUL (FPUL), intrauterine pregnancy (IUP) or EP (including persistent PUL (PPUL)). The M6 models with (M6P ) and without (M6NP ) progesterone were refitted and extended with clinical factors. Model validation was performed using internal-external cross-validation (IECV) (Phase 1) and temporal external validation (EV) (Phase 2). Missing values were handled using multiple imputation. RESULTS Overall, 5473 PUL were recruited over both phases. A total of 709 PUL were excluded because maternal age was < 16 years or initial β-hCG was ≤ 25 IU/L, leaving 4764 (87%) PUL for analysis (2894 in Phase 1 and 1870 in Phase 2). For the refitted M6P model, the area under the receiver-operating-characteristics curve (AUC) for EP/PPUL vs IUP/FPUL was 0.89 for IECV and 0.84-0.88 for EV, with respective sensitivities of 94% and 92-93%. For the refitted M6NP model, the AUCs were 0.85 for IECV and 0.82-0.86 for EV, with respective sensitivities of 92% and 93-94%. Calibration performance was good overall, but with heterogeneity between centers. Net Benefit confirmed clinical utility. The change in AUC when M6P was extended to include maternal age, bleeding score and history of EP was between -0.02 and 0.01, depending on center and phase. The corresponding change in AUC when M6NP was extended was between -0.01 and 0.03. At the 5% threshold to define high risk of EP/PPUL, extending M6P altered sensitivity by -0.02 to -0.01, specificity by 0.03 to 0.04 and Net Benefit by -0.005 to 0.006. Extending M6NP altered sensitivity by -0.03 to -0.01, specificity by 0.05 to 0.07 and Net Benefit by -0.005 to 0.006. CONCLUSIONS The updated M6 model offers accurate diagnostic performance, with excellent sensitivity for EP. Adding clinical factors to the model improved performance in some centers, especially when progesterone levels were not suitable or unavailable. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Kyriacou
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - A Ledger
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - S Bobdiwala
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - F Ayim
- Department of Gynaecology, Hillingdon Hospital NHS Trust, London, UK
| | - E Kirk
- Department of Gynaecology, Royal Free NHS Foundation Trust, London, UK
| | - O Abughazza
- Department of Gynaecology, Royal Surrey County Hospital, Guildford, UK
| | - S Guha
- Department of Gynaecology, Chelsea and Westminster NHS Trust, London, UK
| | - V Vathanan
- Department of Gynaecology, Wexham Park Hospital, London, UK
| | - D Gould
- Department of Gynaecology, St Mary's Hospital, London, UK
| | - D Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Gynecology, University Hospital Leuven, Leuven, Belgium
| | - B Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - T Bourne
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Gynecology, University Hospital Leuven, Leuven, Belgium
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Kyriacou C, Kapur S, Jeyapala S, Parker N, Yang W, Pikovsky M, Bobdiwala S, Barcroft J, Maheetharan S, Sur S, Stalder C, Gould D, Syed S, Tan T, Bourne T. Beta-human chorionic gonadotrophin point of care testing for the management of pregnancy of unknown location. Reprod Biomed Online 2024; 48:103643. [PMID: 38262209 DOI: 10.1016/j.rbmo.2023.103643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 01/25/2024]
Abstract
RESEARCH QUESTION Does a commercially available quantitative beta-human chorionic gonadotrophin (BHCG) point of care testing (POCT) device improve workflow management in early pregnancy by performing comparably to gold standard laboratory methods, and is the performance of a validated pregnancy of unknown location (PUL) triage strategy maintained using POCT BHCG results? DESIGN Women classified with a PUL between 2018 and 2021 at three early pregnancy units were included. The linear relationship of untreated whole-blood POCT and serum laboratory BHCG values was defined using coefficients and regression. Paired serial BHCG values were then incorporated into the validated M6 multinomial logistic regression model to stratify the PUL as at high risk or at low risk of clinical complications. The sensitivity and negative predictive value were assessed. The timings required for equivocal POCT and laboratory care pathways were compared. RESULTS A total of 462 PUL were included. The discrepancy between 571 laboratory and POCT BHCG values was -5.2% (-6.2 IU/l), with a correlation coefficient of 0.96. The 133 PUL with paired 0 and 48 h BHCG values were compared using the M6 model. The sensitivity for high-risk outcomes (96.2%) and negative predictive values (98.5%) was excellent for both. Sample receipt and laboratory processing took 135 min (421 timings), compared with 12 min (91 timings) when using POCT (P < 0.0001). CONCLUSIONS POCT BHCG values correlated well with laboratory testing measurements. The M6 model retained its performance when using POCT BHCG values. Using the model with POCT may improve workflow and patient care without compromising on effective PUL triage.
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Affiliation(s)
- Christopher Kyriacou
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Shikha Kapur
- Gynaecology Emergency Unit, Department of Obstetrics and Gynaecology, St Mary's Hospital, Imperial College London, London, UK
| | - Sobanakumari Jeyapala
- Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Hillingdon Hospital, London, UK
| | - Nina Parker
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Wei Yang
- Biochemistry unit, Department of Laboratory Diagnostics, Hammersmith Hospital, Imperial College London, London, UK
| | - Margaret Pikovsky
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Shabnam Bobdiwala
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Jennifer Barcroft
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Shanuja Maheetharan
- Biochemistry unit, Department of Laboratory Diagnostics, Hammersmith Hospital, Imperial College London, London, UK
| | - Shyamaly Sur
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Catriona Stalder
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - Deborah Gould
- Gynaecology Emergency Unit, Department of Obstetrics and Gynaecology, St Mary's Hospital, Imperial College London, London, UK
| | - Shabana Syed
- Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Hillingdon Hospital, London, UK
| | - Tricia Tan
- Biochemistry unit, Department of Laboratory Diagnostics, Hammersmith Hospital, Imperial College London, London, UK
| | - Tom Bourne
- Tommy's National Centre for Miscarriage Research, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
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Hirschler LE, Soti V. The Utility of Monitoring Beta-Human Chorionic Gonadotropin Levels in an Ectopic Pregnancy. Cureus 2023; 15:e34063. [PMID: 36699108 PMCID: PMC9867943 DOI: 10.7759/cureus.34063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Ectopic pregnancy, a rare complication involving embryo nidation outside the uterus, significantly impacts women's lives worldwide. About 95% of ectopic pregnancies occur in the Fallopian tubes. If not diagnosed early, the patient may suffer from tubal rupture, resulting in hemorrhage and lethal consequences. Transvaginal ultrasound (TVUS) is typically used to diagnose an ectopic pregnancy. However, over the last decade, monitoring beta-human chorionic gonadotropin (β-hCG) levels in ectopic pregnancy have evolved to detect ectopic pregnancy. But there are inconsistencies in its utility in monitoring or diagnosing ectopic pregnancy in clinical practice. This systematic review highlights the potential of monitoring β-hCG levels to accurately diagnose ectopic pregnancy. Furthermore, it showcases if β-hCG levels can determine effective treatment options to successfully resolve an ectopic pregnancy. We performed a literature search between January 2022 through December 2022 following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The clinical evidence demonstrated that monitoring β-hCG levels, combined with TVUS, accurately diagnosed an ectopic pregnancy. Moreover, pre-treatment β-hCG levels higher than 5000 international units per liter (IU/L), statistically significant, indicated surgical management for a successful resolution of an ectopic pregnancy. Whereas lower β-hCG levels showed successful management through expectant and methotrexate treatment. Interestingly, patients who failed non-surgical treatment developed increased β-hCG levels and required surgical intervention. However, there was conflicting evidence on whether β-hCG levels could indicate tubal rupture. Nevertheless, as highlighted in this review, monitoring β-hCG levels could be crucial in the early diagnosis of ectopic pregnancy. Besides, it might significantly aid in monitoring and deciding on effective treatment options for patients with ectopic pregnancy, which could be vital to saving their lives and preserving fertility.
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Affiliation(s)
| | - Varun Soti
- Pharmacology and Therapeutics, Lake Erie College of Osteopathic Medicine, Elmira, USA
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Shazly SA, Radwan AA, Abdo MS, Moustafa HY, Abd-Elkariem AY, Ali SS, Ahmed NB, Hosny EM, Abouzeid MH, Eltaweel NA, Hortu I, Abdelbadie AS, Fahmy MS, Attyia MI, Shawki AA, Said AE, Mohamed YI, Hemdan HN, Hemdan MN, Mohamed NG, Adam RI. Middle-East obgyn graduate education (MOGGE) foundation practice guidelines: diagnostic approach to pregnancy of unknown location: practice guideline no. 03-O-21. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2022. [DOI: 10.1186/s43043-022-00114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pregnancy of unknown location (PUL) is a term used to describe failure of visualization of intrauterine or extrauterine gestational sac in a woman with a positive pregnancy test.
Body of the abstract
Ectopic pregnancy (EP) accounts for 1–2 % of all pregnancies. EP contributes to maternal mortality of a known cause by 4% in developed countries. However, case fatality rate may be 10 times higher in low-resource countries. This may be attributed to delayed diagnosis and lack of resources. PUL is a temporary term that may eventually lead to diagnosis of viable intrauterine pregnancy, pregnancy loss, or more seriously, EP.
Conclusion
This guideline appraises current evidence on assessment of PUL and early diagnosis of EP particularly in low-resource settings.
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11
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Cirillo F, Paladino I, Ronchetti C, Busnelli A, Morenghi E, Grilli L, Patrizio P, Zannoni E, Levi-Setti PE. Ectopic pregnancy risk factors in infertile patients: a 10-year single center experience. Sci Rep 2022; 12:20473. [PMID: 36443354 PMCID: PMC9705323 DOI: 10.1038/s41598-022-24649-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022] Open
Abstract
The present retrospective study included both intrauterine insemination and in vitro assisted reproductive technologies (ART) procedures performed from January 2009 to December 2018 at a tertiary-care Fertility Centre. The purpose was to assess the incidence of ectopic pregnancy (EP) in infertile population who undergoes ART and to identify any risk factor impacting the occurrence of EP after ART. Among 27,376 cycles, 7352 pregnancies were achieved, of which 132 were EPs, the 1.80% (95% CI 1.5-2.1) of all pregnancies. In fresh embryo transfer cycles, a history of prior pelvic adhesions showed the greatest impact on the incidence of EP (aOR 2.49 95% CI 1.53-4.07 p < 0.001). Other factors associated with EP incidence were also identified, such as female age, basal FSH, the transfer of blastocyst embryos and difficulties during the embryo transfer procedure. In frozen embryo transfer cycles, the only factor influencing the incidence of EP was anti Müllerian hormone (AMH) serum concentration (aOR 0.81 95% CI 0.65-1.00, p = 0.048). To conclude, the incidence of EP observed was comparable to that reported after natural conception. On the other hand, pre-existing risk factors, traditionally more common in infertile population, appeared to influence the incidence of EP and should thus be modified if possible.
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Affiliation(s)
- Federico Cirillo
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ilaria Paladino
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Camilla Ronchetti
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Busnelli
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Emanuela Morenghi
- grid.417728.f0000 0004 1756 8807Biostatistics Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Leonora Grilli
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pasquale Patrizio
- grid.26790.3a0000 0004 1936 8606Division Reproductive Endocrinology and Infertility, University of Miami, Miller School of Medicine, Miami, FL USA
| | - Elena Zannoni
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- grid.417728.f0000 0004 1756 8807Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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12
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Jar-Allah T, Hognert H, Köcher L, Berggren L, Fiala C, Milsom I, Gemzell-Danielsson K. Detection of ectopic pregnancy and serum beta hCG levels in women undergoing very early medical abortion: a retrospective cohort study. EUR J CONTRACEP REPR 2022; 27:240-246. [DOI: 10.1080/13625187.2022.2025587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Tagrid Jar-Allah
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Hognert
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Laura Köcher
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Linus Berggren
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christian Fiala
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
- GynMed Clinic, Vienna, Austria
| | - Ian Milsom
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
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13
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Kyriacou C, Cooper N, Robinson E, Parker N, Barcroft J, Kundu S, Letchworth P, Sur S, Gould D, Stalder C, Bourne T. Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:909-915. [PMID: 34605083 PMCID: PMC8661840 DOI: 10.1002/uog.24793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/14/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic. METHODS This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management. RESULTS There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020. CONCLUSIONS No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. Kyriacou
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - N. Cooper
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - E. Robinson
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - N. Parker
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - J. Barcroft
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - S. Kundu
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - P. Letchworth
- St Mary's Hospital, Department of Obstetrics and GynaecologyImperial College LondonLondonUK
| | - S. Sur
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - D. Gould
- St Mary's Hospital, Department of Obstetrics and GynaecologyImperial College LondonLondonUK
| | - C. Stalder
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
| | - T. Bourne
- Tommy's National Centre for Miscarriage Research, Department of Obstetrics and Gynaecology, Queen Charlotte's & Chelsea HospitalImperial College LondonLondonUK
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
- Department of Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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14
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Bobdiwala S, Kyriacou C, Christodoulou E, Farren J, Mitchell-Jones N, Al-Memar M, Ayim F, Chohan B, Kirk E, Abughazza O, Guruwadahyarhalli B, Guha S, Vathanan V, Gould D, Stalder C, Timmerman D, Van Calster B, Bourne T. Evaluating cut-off levels for progesterone, β human chorionic gonadotropin and β human chorionic gonadotropin ratio to exclude pregnancy viability in women with a pregnancy of unknown location: A prospective multicenter cohort study. Acta Obstet Gynecol Scand 2021; 101:46-55. [PMID: 34817062 DOI: 10.1111/aogs.14295] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/13/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is no global agreement on how to best determine pregnancy of unknown location viability and location using biomarkers. Measurements of progesterone and β human chorionic gonadotropin (βhCG) are still used in clinical practice to exclude the possibility of a viable intrauterine pregnancy (VIUP). We evaluate the predictive value of progesterone, βhCG, and βhCG ratio cut-off levels to exclude a VIUP in women with a pregnancy of unknown location. MATERIAL AND METHODS This was a secondary analysis of prospective multicenter study data of consecutive women with a pregnancy of unknown location between January 2015 and 2017 collected from dedicated early pregnancy assessment units of eight hospitals. Single progesterone and serial βhCG measurements were taken. Women were followed up until final pregnancy outcome between 11 and 14 weeks of gestation was confirmed using transvaginal ultrasonography: (1) VIUP, (2) non-viable intrauterine pregnancy or failed pregnancy of unknown location, and (3) ectopic pregnancy or persisting pregnancy of unknown location. The predictive value of cut-off levels for ruling out VIUP were evaluated across a range of values likely to be encountered clinically for progesterone, βhCG, and βhCG ratio. RESULTS Data from 2507 of 3272 (76.6%) women were suitable for analysis. All had data for βhCG levels, 2248 (89.7%) had progesterone levels, and 1809 (72.2%) had βhCG ratio. The likelihood of viability falls with the progesterone level. Although the median progesterone level associated with viability was 59 nmol/L, VIUP were identified with levels as low as 5 nmol/L. No single βhCG cut-off reliably ruled out the presence of viability with certainty, even when the level was more than 3000 IU/L, there were 39/358 (11%) women who had a VIUP. The probability of viability decreases with the βhCG ratio. Although the median βhCG ratio associated with viability was 2.26, VIUP were identified with ratios as low as 1.02. A progesterone level below 2 nmol/L and βhCG ratio below 0.87 were unlikely to be associated with viability but were not definitive when considering multiple imputation. CONCLUSIONS Cut-off levels for βhCG, βhCG ratio, and progesterone are not safe to be used clinically to exclude viability in early pregnancy. Although βhCG ratio and progesterone have slightly better performance in comparison, single βhCG used in this manner is highly unreliable.
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Affiliation(s)
- Shabnam Bobdiwala
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Christopher Kyriacou
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Evangelia Christodoulou
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Department of Cancer Epidemiology, DKFZ, Heidelberg, Germany
| | - Jessica Farren
- Department of Gynaecology, St Mary's Hospital, London, UK
| | | | - Maya Al-Memar
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Francis Ayim
- Department of Gynaecology, Hillingdon Hospital NHS Trust, London, UK
| | | | - Emma Kirk
- Department of Gynaecology, Royal Free NHS Foundation Trust, London, UK
| | - Osama Abughazza
- Department of Gynaecology, Royal Surrey County Hospital, Guildford, UK
| | | | - Sharmistha Guha
- Department of Gynaecology, Chelsea and Westminster NHS Trust, London, UK
| | | | - Debbie Gould
- Department of Gynaecology, St Mary's Hospital, London, UK
| | - Catriona Stalder
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Dirk Timmerman
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Department of Gynecology, University Hospital Leuven, Leuven, Belgium
| | - Ben Van Calster
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Tom Bourne
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK.,Department of Development & Regeneration, KU Leuven, Leuven, Belgium
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15
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Nadim B, Leonardi M, Stamatopoulos N, Reid S, Condous G. External validation of risk prediction model M4 in an Australian population: Rationalising the management of pregnancies of unknown location. Aust N Z J Obstet Gynaecol 2020; 60:928-934. [PMID: 32538482 DOI: 10.1111/ajo.13201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prediction model M4 can successfully classify pregnancy of unknown location (PUL) into a low- or high-risk group in developing ectopic pregnancy. M4 was validated in UK centres but in very few other countries outside UK. AIM To validate the M4 model's ability to correctly classify PULs in a cohort of Australian women. MATERIALS AND METHODS A retrospective analysis of women classified with PUL, attending a Sydney-based teaching hospital between 2006 and 2018. The reference standard was the final characterisation of PUL: failed PUL (FPUL) or intrauterine pregnancy (IUP; low risk) vs ectopic pregnancy (EP) or persistent PUL (PPUL; high risk). Each patient was entered into the M4 model calculator and an estimated risk of FPUL/IUP or EP/PPUL was recorded. Diagnostic accuracy of the M4 model was evaluated. RESULTS Of 9077 consecutive women who underwent transvaginal sonography, 713 (7.9%) classified with a PUL. Six hundred and seventy-seven (95.0%) had complete study data and were included. Final outcomes were: 422 (62.3%) FPULs, 150 (22.2%) IUPs, 105 (15.5%) EPs and PPULs. The M4 model classified 455 (67.2%) as low-risk PULs of which 434 (95.4%) were FPULs/IUPs and 21 (4.6%) were EPs or PPULs. EPs/PPULs were correctly classified with sensitivity of 80.0% (95% CI 71.1-86.5%), specificity of 75.9% (95% CI 72.2-79.3%), positive predictive value of 37.8% (95% CI 33.8-42.1%) and negative predictive value of 95.3% (95% CI 93.1-96.9%). CONCLUSIONS We have externally validated the prediction model M4. It classified 67.2% of PULs as low risk, of which 95.4% were later characterised as FPULs or IUPs while still classifying 80.0% of EPs as high risk.
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Affiliation(s)
- Batool Nadim
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopic Surgery Unit, Nepean Hospital, Nepean Clinical School University of Sydney, Sydney, New South Wales, Australia
| | - Mathew Leonardi
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopic Surgery Unit, Nepean Hospital, Nepean Clinical School University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Stamatopoulos
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopic Surgery Unit, Nepean Hospital, Nepean Clinical School University of Sydney, Sydney, New South Wales, Australia
| | - Shannon Reid
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopic Surgery Unit, Nepean Hospital, Nepean Clinical School University of Sydney, Sydney, New South Wales, Australia
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16
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Lu Q, Wang Y, Sun X, Li Y, Wang J, Zhou Y, Wang Y. The diagnostic role of the β-hCG discriminatory zone combined with the endometrial pattern for ectopic pregnancy in Chinese women. Sci Rep 2019; 9:13781. [PMID: 31551446 PMCID: PMC6760119 DOI: 10.1038/s41598-019-50151-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/06/2019] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Qi Lu
- Department of Gynecology, Jinshan Hospital of Fudan University, 1508 Longhang Rd., Shanghai, 201508, China
| | - Yiwei Wang
- Department of Gynecology, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine, 910 Hengshan Rd., Shanghai, 200030, China
| | - Xiao Sun
- Department of Gynecology, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine, 910 Hengshan Rd., Shanghai, 200030, China
| | - Yuhong Li
- Department of Gynecology, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine, 910 Hengshan Rd., Shanghai, 200030, China
| | - Jing Wang
- Department of Gynecology, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine, 910 Hengshan Rd., Shanghai, 200030, China
| | - Yun Zhou
- Department of Ultrasound in Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine, 910 Hengshan Rd., Shanghai, 200030, China.
| | - Yudong Wang
- Department of Gynecology, International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine, 910 Hengshan Rd., Shanghai, 200030, China.
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17
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Young L, Necas M. The clinical outcome of pregnancies of unknown location: an audit of 112 cases. SONOGRAPHY 2019. [DOI: 10.1002/sono.12173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Lee Young
- Department of Ultrasound, Radiology; Waikato Hospital; Hamilton New Zealand
| | - Martin Necas
- Department of Ultrasound, Radiology; Waikato Hospital; Hamilton New Zealand
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18
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Memtsa M, Jurkovic D, Jauniaux ERM. Diagnostic Biomarkers for Predicting Adverse Early Pregnancy Outcomes. BJOG 2018; 126:e107-e113. [DOI: 10.1111/1471-0528.15468] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Bobdiwala S, Saso S, Verbakel JY, Al-Memar M, Van Calster B, Timmerman D, Bourne T. Diagnostic protocols for the management of pregnancy of unknown location: a systematic review and meta-analysis. BJOG 2018; 126:190-198. [PMID: 30129999 DOI: 10.1111/1471-0528.15442] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is no international consensus on how to manage women with a pregnancy of unknown location (PUL). OBJECTIVES To present a systematic quantitative review summarising the evidence related to management protocols for PUL. SEARCH STRATEGY MEDLINE, COCHRANE and DARE databases were searched from 1 January 1984 to 31 January 2017. The primary outcome was accurate risk prediction of women initially diagnosed with a PUL having an ectopic pregnancy (high risk) as opposed to either a failed PUL or intrauterine pregnancy (low risk). SELECTION CRITERIA All studies written in the English language, which were not case reports or series that assessed women classified as having a PUL at initial ultrasound. DATA COLLECTION AND ANALYSIS Forty-three studies were included. QUADAS-2 criteria were used to assess the risk of bias. We used a novel, linear mixed-effects model and constructed summary receiver operating characteristic curves for the thresholds of interest. MAIN RESULTS There was a high risk of differential verification bias in most studies. Meta-analyses of accuracy were performed on (i) single human chorionic gonadotrophin (hCG) cut-off levels, (ii) hCG ratio (hCG at 48 hours/initial hCG), (iii) single progesterone cut-off levels and (iv) the 'M4 model' (a logistic regression model based on the initial hCG and hCG ratio). For predicting an ectopic pregnancy, the areas under the curves (95% CI) for these four management protocols were as follows: (i) 0.42 (0.00-0.99), (ii) 0.69 (0.57-0.78), (iii) 0.69 (0.54-0.81) and (iv) 0.87 (0.83-0.91), respectively. CONCLUSIONS The M4 model was the best available method for predicting a final outcome of ectopic pregnancy. Developing and validating risk prediction models may optimise the management of PUL. TWEETABLE ABSTRACT Pregnancy of unknown location meta-analysis: M4 model has best test performance to predict ectopic pregnancy.
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Affiliation(s)
- S Bobdiwala
- Tommys' National Centre for Miscarriage Research, Imperial College, London, UK
| | - S Saso
- Tommys' National Centre for Miscarriage Research, Imperial College, London, UK
| | - J Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - M Al-Memar
- Tommys' National Centre for Miscarriage Research, Imperial College, London, UK
| | - B Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - D Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - T Bourne
- Tommys' National Centre for Miscarriage Research, Imperial College, London, UK.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
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20
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Eom JM, Choi JS, Bae J, Lee WM, Lee E, Lee J, Keum JH. Coexisting ovarian and tubal pregnancies on opposite sides after intrauterine insemination: a case report. BMC Pregnancy Childbirth 2018; 18:259. [PMID: 29940883 PMCID: PMC6019221 DOI: 10.1186/s12884-018-1801-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/30/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Ovarian pregnancy is very rare, and contralateral tubal pregnancy coexisting with ovarian pregnancy must be even rarer. CASE PRESENTATION A 33-year-old Korean nulliparous woman was referred to our hospital because she suffered lower abdominal pain and had missed her periods after controlled ovarian hyperstimulation and intrauterine insemination. We could not identify any normal gestational sac in the endometrium, or specific ectopic pregnancies, on an initial ultrasound scan. However, there was a large hematoma in the cul-de-sac and free fluid in the right paracolic gutter. We decided to perform emergent laparoscopic surgery. We found contralateral tubal and ovarian ectopic pregnancies. CONCLUSION To the best of our knowledge, this is the first report of a case in which a patient underwent laparoscopic right salpingectomy and left ovarian ectopic mass excision due to contralateral tubal and ovarian ectopic pregnancies after assisted reproductive technology.
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Affiliation(s)
- Jeong Min Eom
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Joong Sub Choi
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea.
| | - Jaeman Bae
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Won Moo Lee
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Eunhyun Lee
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Jongwon Lee
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Ji Hyun Keum
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Full time faculty of the Department of Obstetrics and Gynecology, Hanyang University College of Medicine, 222-1 Wangsimni-ro Seongdong-gu, Seoul, 04763, Republic of Korea
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Robertson JJ, Long B, Koyfman A. Emergency Medicine Myths: Ectopic Pregnancy Evaluation, Risk Factors, and Presentation. J Emerg Med 2017; 53:819-828. [PMID: 29110976 DOI: 10.1016/j.jemermed.2017.08.074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Ectopic pregnancy (EP) is an important cause of morbidity and mortality in females of reproductive age. Proper diagnosis and treatment are critical, as complications such as rupture, hemorrhagic shock, and even death can occur. OBJECTIVE EP is a condition emergency physicians are trained to detect, yet there are multiple myths concerning its evaluation and diagnosis. This article reviews several of these myths in order to improve emergency department (ED) evaluation and diagnosis. DISCUSSION EP is a difficult diagnosis and may be missed on initial ED visit. While the diagnosis is often delayed simply due to very early presentations, it can also be missed because patients may not have all the same risk factors or demonstrate the same symptoms. They may also not demonstrate the same serum B-human chorionic gonadotropin levels and trends or have the same ultrasound findings at equivalent gestational ages. Some patients with early EP may have positive ultrasound findings with serum β-hCG levels under a defined discriminatory zone (DZ). On the other hand, some patients with an early viable intrauterine pregnancy may have no visible findings on initial ultrasound, but have serum β-hCG (quantitative) levels well above the DZ. Although rare, EP has even been demonstrated in women with negative urine β-hCG tests or low serum β-hCG levels. CONCLUSIONS While EP may be a challenging diagnosis, understanding the myths surrounding EP may help emergency physicians consider it, even when patient risk factors, symptoms, or ED laboratory or imaging studies do not initially or easily define the diagnosis.
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Affiliation(s)
| | - Brit Long
- San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- University of Texas-Southwestern, Parkland Hospital, Dallas, Texas
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22
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Phillips CH, Wortman JR, Ginsburg ES, Sodickson AD, Doubilet PM, Khurana B. First-trimester emergencies: a radiologist's perspective. Emerg Radiol 2017; 25:61-72. [PMID: 28948411 DOI: 10.1007/s10140-017-1556-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/13/2017] [Indexed: 12/27/2022]
Abstract
The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.
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Affiliation(s)
- Catherine H Phillips
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Jeremy R Wortman
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Elizabeth S Ginsburg
- Department of Infertility and Reproductive Surgery, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Bharti Khurana
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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23
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Abstract
Pelvic pain is a common complaint in female patients who present to the emergency department. Although encountered frequently, the path to a definitive diagnosis is not always a straightforward one, and imaging offers a valuable tool to aid in this diagnostic challenge. Radiologists must be familiar with the most common etiologies of female pelvic pain in the emergency setting, their imaging characteristics, and the best way to further evaluate challenging clinical presentations. This allows the radiologist to serve as a valuable asset to the treating physician, aiding in accurate diagnosis, and in guiding the course of treatment, all while ensuring the "Image Wisely" principle. A sonographic approach to female patients presenting to the emergency setting with pelvic pain has been presented in this article and some example entities along with their imaging findings have also been reviewed.
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Affiliation(s)
- Daniel P Thut
- Department of Radiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA.
| | - Michael S Morrow
- Department of Radiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Christopher C Moore
- Department of Radiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
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24
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Abstract
The management of women with a pregnancy of unknown location (PUL) can vary significantly and often lacks a clear evidence base. Intensive follow-up is usually required for women with a final outcome of an ectopic pregnancy. This, however, only accounts for a small proportion of women with a pregnancy of unknown PUL location. There remains a clear clinical need to rationalize the follow-up of PUL so women at high risk of having a final outcome of an ectopic pregnancy are followed up more intensively and those PUL at low risk of having an ectopic pregnancy have their follow-up streamlined. This review covers the main management strategies published in the current literature and aims to give clinicians an overview of the most up-to-date evidence that they can take away into their everyday clinical practice when caring for women with a PUL.
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Affiliation(s)
- Shabnam Bobdiwala
- 1 Tommys' National Centre for Miscarriage Research, Queen Charlottes' & Chelsea Hospital, Imperial College, London, UK
| | - Maya Al-Memar
- 1 Tommys' National Centre for Miscarriage Research, Queen Charlottes' & Chelsea Hospital, Imperial College, London, UK
| | - Jessica Farren
- 1 Tommys' National Centre for Miscarriage Research, Queen Charlottes' & Chelsea Hospital, Imperial College, London, UK
| | - Tom Bourne
- 1 Tommys' National Centre for Miscarriage Research, Queen Charlottes' & Chelsea Hospital, Imperial College, London, UK.,2 Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,3 Department of Obstetrics and Gynaecology, University Hospitals Leuven, Campus Gasthuisberg, KU Leuven, Leuven, Belgium
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Farahani L, Sinha A, Lloyd J, Islam M, Ross JA. Negative histology with surgically treated tubal ectopic pregnancies - A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 213:98-101. [PMID: 28441571 DOI: 10.1016/j.ejogrb.2017.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 03/19/2017] [Accepted: 04/01/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the outcome of histological examinations of surgical specimens obtained from treatment of tubal ectopic pregnancy and to correlate with clinical findings, pre-operative ultrasound scans and the type of surgery. STUDY DESIGN A retrospective cohort study of 941 women diagnosed with a tubal ectopic pregnancy in the Early Pregnancy Unit and having surgical treatment at King's College Hospital, London. Clinical and ultrasound data had been entered contemporaneously on our electronic early pregnancy database and hospital clinical records over an 11year period from 2004 to 2014. Demographic data, clinical history, ultrasound scan parameters, type of surgical management and histological diagnosis were recorded. The primary outcome measure was the presence or absence of chorionic villi in the surgical specimen. Data were analysed using Mann Whitney U test for non-parametric data, relative risk for categorical data and binomial logistic regression. RESULTS A surgical specimen was obtained in 925 cases. Of these, 881/925 (95.2%) were positive for the presence of chorionic villi on histological examination. Patients with negative histology had a lower median gestational age, smaller ectopic pregnancies and lower serum human chorionic gonadotrophin levels. The relative risk of negative histology was significantly higher with a solid ectopic pregnancy on ultrasound (RR1.91, 95% CI 1.07-3.4) and with conservative surgery (RR 3.68, 95% CI 1.25-10.77). The relative risk was significantly lower with the presence of embryonic cardiac activity (RR 0.12, 95% CI 0.02-0.85). Only the serum hCG level was a significant predictor of negative histology on logistic regression analysis (p=0.048). In 39/44 women with negative histology, the human chorionic gonadotrophin level declined after surgery with no further intervention. Five of the 44 required a second surgical procedure as the ectopic pregnancy had been missed at the initial surgery and did not resolve. CONCLUSION There is lack of histological confirmation of sonographically diagnosed and surgically confirmed ectopic pregnancies in approximately 5% of cases, making this a relatively common finding following surgical treatment of tubal ectopic pregnancy. Clinicians should be aware of this when counselling women with tubal ectopic pregnancies about to undergo surgery, include this risk in the consent process and plan post-surgical follow up with this in mind.
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Affiliation(s)
- Linda Farahani
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Anjita Sinha
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Jilly Lloyd
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Melissa Islam
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Jackie A Ross
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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26
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Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2017; 69:241-250.e20. [DOI: 10.1016/j.annemergmed.2016.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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27
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28
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Odejinmi F, Huff KO, Oliver R. Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2016; 210:69-75. [PMID: 27940397 DOI: 10.1016/j.ejogrb.2016.10.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/21/2016] [Indexed: 11/30/2022]
Abstract
Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.
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Affiliation(s)
- Funlayo Odejinmi
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK.
| | - Keren O Huff
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
| | - Reeba Oliver
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
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29
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Morin L, Cargill YM, Glanc P. Ultrasound Evaluation of First Trimester Complications of Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:982-988. [DOI: 10.1016/j.jogc.2016.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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30
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Morin L, Cargill YM, Glanc P. Archivée: Évaluation échographique des complications au premier trimestre de grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:989-996. [DOI: 10.1016/j.jogc.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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31
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Hamza A, Meyberg-Solomayer G, Juhasz-Böss I, Joukhadar R, Takacs Z, Solomayer EF, Baum S, Radosa J, Mavrova L, Herr D. Diagnostic Methods of Ectopic Pregnancy and Early Pregnancy Loss: a Review of the Literature. Geburtshilfe Frauenheilkd 2016; 76:377-382. [PMID: 27134292 DOI: 10.1055/s-0041-110204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review article presents recent evidence on early pregnancy loss and ectopic pregnancy. In the light of recent evidence, the β-hCG discriminatory zone may be extended in clinically stable cases without evidence of bleeding. A possible cut-off is 4300 mIU/ml, which corresponds to when a sonographer should detect an intrauterine pregnancy. Embryonic demise can be confirmed when a transvaginal ultrasound finding shows no heartbeat in an embryo of more than 7 mm CRL, no embryo in a gestational sac having a mean sac diameter of more than 25 mm, or no appearance of an embryo within 7-10 days after the primary examination. These are considered definitive signs of embryonic demise. Suggestive signs of embryonic demise require closer monitoring of the pregnancy.
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Affiliation(s)
- A Hamza
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - G Meyberg-Solomayer
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - I Juhasz-Böss
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - R Joukhadar
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - Z Takacs
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - E-F Solomayer
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - S Baum
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - J Radosa
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - L Mavrova
- Department of Obstetrics and Gynaecology, Homburg University Medical Centre, Homburg
| | - D Herr
- Department of Obstetrics and Gynaecology, Würzburg University Medical Centre, Würzburg
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32
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Gerges B, Condous G. Minimising harm in the early pregnancy population. Aust N Z J Obstet Gynaecol 2015; 55:521-2. [PMID: 26437835 DOI: 10.1111/ajo.12412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Bassem Gerges
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, New South Wales, Australia.
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Kingswood, New South Wales, Australia.,Omni Gynaecological Care Centre for Women's Ultrasound and Early Pregnancy, St Leonards, New South Wales, Australia
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33
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Cabar FR, Pereira PP, Schultz R, Francisco RP, Zugaib M. Association between ultrasound findings and serum levels of vascular endothelial growth factor in ampullary pregnancy. Fertil Steril 2015; 103:734-7. [PMID: 25577466 DOI: 10.1016/j.fertnstert.2014.12.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the association between ultrasound images and serum concentrations of vascular endothelial growth factor (VEGF) in ampullary pregnancies. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Fifty patients with ampullary pregnancy. INTERVENTION(S) Criteria for inclusion in the study were: singleton pregnancy from spontaneous conception; diagnosis of tubal pregnancy in the ampullary region; radical surgical treatment (salpingectomy); and measurement of serum VEGF, human chorionic gonadotropin, and progesterone on the day of surgery. An additional criterion was description of an ectopic mass by transvaginal ultrasound, as follows: [1] ectopic gestational sac containing an embryo with cardiac activity; and [2] tubal ring: a paraovarian formation similar to a gestational sac, not containing a viable embryo (an anechoic structure surrounded by a peripheral hyperechogenic halo); an empty ectopic gestational sac; a sac containing an embryo without cardiac activity; or a vitelline vesicle. MAIN OUTCOME MEASURE(S) Association between ultrasound images and serum concentrations of VEGF. RESULT(S) An association was found between ultrasonographic images and VEGF serum concentrations. Ectopic embryos with cardiac activity were associated with higher levels of serum VEGF. CONCLUSION(S) In ampullary pregnancy, higher serum levels of VEGF are associated with the finding of an embryo with cardiac activity on transvaginal ultrasound. Greater production of VEGF likely creates development conditions more conducive to ectopic embryos.
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Affiliation(s)
- Fábio Roberto Cabar
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil.
| | - Pedro Paulo Pereira
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil
| | - Regina Schultz
- Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Marcelo Zugaib
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil
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34
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Menakaya UA, Adno A, Burnet S, Trivedi A, Smoleniec J, Condous G. Acute gynaecological services in Australia--time for a change. Aust N Z J Obstet Gynaecol 2014; 54:195-7. [PMID: 24888593 DOI: 10.1111/ajo.12218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Uchefuna A Menakaya
- Acute Gynaecology, Early Pregnancy Unit and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, Sydney, NSW, Australia.
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35
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Guha S, Ayim F, Ludlow J, Sayasneh A, Condous G, Kirk E, Stalder C, Timmerman D, Bourne T, Van Calster B. Triaging pregnancies of unknown location: the performance of protocols based on single serum progesterone or repeated serum hCG levels. Hum Reprod 2014; 29:938-45. [DOI: 10.1093/humrep/deu045] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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36
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37
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Infante F, Menakaya U, Condous G. Medical treatment of ectopic pregnancy. Fertil Steril 2014; 101:e16. [PMID: 24424361 DOI: 10.1016/j.fertnstert.2013.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/06/2013] [Indexed: 11/15/2022]
Affiliation(s)
- Fernando Infante
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, New South Wales, Australia
| | - Uche Menakaya
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, New South Wales, Australia
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, New South Wales, Australia; OMNI Gynaecological Care, Centre for Women's Ultrasound and Early Pregnancy, St. Leonards, Sydney, New South Wales, Australia
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38
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Doubilet PM, Benson CB, Bourne T, Blaivas M, Barnhart KT, Benacerraf BR, Brown DL, Filly RA, Fox JC, Goldstein SR, Kendall JL, Lyons EA, Porter MB, Pretorius DH, Timor-Tritsch IE. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med 2013; 369:1443-51. [PMID: 24106937 DOI: 10.1056/nejmra1302417] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Peter M Doubilet
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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39
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Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update 2013; 20:250-61. [DOI: 10.1093/humupd/dmt047] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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40
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Pitfalls in emergency department focused bedside sonography of first trimester pregnancy. Emerg Med Int 2013; 2013:982318. [PMID: 23997954 PMCID: PMC3753733 DOI: 10.1155/2013/982318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/18/2013] [Indexed: 12/27/2022] Open
Abstract
Background. Bedside sonography performed by emergency physicians is frequently utilized for real-time clinical decision-making in the emergency department (ED) setting. This includes the sonographic evaluation of pain or bleeding in the first trimester of pregnancy. The detection of intrauterine pregnancy (IUP) or life-threatening conditions, including ectopic pregnancy, is critical. Objectives. This paper will review several important pearls and avoidable pitfalls of this diagnostic modality by brief presentation of illustrative cases followed by discussion of key principles. Case Reports. Three patients evaluated in the ED for bleeding or pain occurring during the first trimester of pregnancy will be presented. Conclusions. When conducting emergency bedside ultrasound for the evaluation of first trimester pregnancy, it is important to avoid common pitfalls that can place your patient at risk.
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41
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Smith LP, Oskowitz SP, Dodge LE, Hacker MR. Risk of ectopic pregnancy following day-5 embryo transfer compared with day-3 transfer. Reprod Biomed Online 2013; 27:407-13. [PMID: 23953586 DOI: 10.1016/j.rbmo.2013.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Abstract
The incidence of ectopic pregnancy after IVF is increased approximately 2.5-5-fold compared with natural conceptions; however, the aetiology for this increased risk remains unclear. One proposed practice change to decrease the incidence of ectopic pregnancy is blastocyst embryo transfer on day 5 rather than cleavage-stage embryo transfer on day 3. A retrospective cohort study was conducted to compare the risk of ectopic pregnancy following fresh day-5 embryo transfer with day-3 embryo transfer among women who underwent IVF and achieved pregnancy from 1998 to 2011. There were 13,654 eligible pregnancies; 277 were ectopic. The incidence of ectopic pregnancy was 2.1% among day-3 pregnancies and 1.6% among day-5 pregnancies. The adjusted risk ratio for ectopic pregnancy from day-5 compared with day-3 transfer was 0.71 (95% confidence interval 0.46-1.10). Although this analysis included 13,654 cycles, with a two-sided significance level of 0.05, it had only 21.9% power to detect a difference between the low incidence of ectopic pregnancy among both day-3 and day-5 transfers. In conclusion, this study was not able to demonstrate a difference in the risk of ectopic pregnancy among day-3 compared with day-5 transfers.
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Affiliation(s)
- Laura P Smith
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Kirstein 3, Boston, MA 02215, USA; Boston IVF, 130 Second Avenue, Waltham, MA 02451, USA; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Reproductive Medicine and Surgery Center of Virginia, 595 Martha Jefferson Drive, Suite 390, Charlottesville, VA 22911, USA
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42
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Reid S, Condous G. Is there a need to definitively diagnose the location of a pregnancy of unknown location? The case for "no". Fertil Steril 2013; 98:1085-90. [PMID: 23084010 DOI: 10.1016/j.fertnstert.2012.09.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 11/25/2022]
Abstract
The ability to predict the outcome of a pregnancy of unknown location (PUL) has been extensively studied over the past decade. Between 8%-14% of PULs will develop into ectopic pregnancies (EP), and therefore the need to confirm pregnancy location is not without good reason. Strategies to predict EP in the PUL population have included the use of various maternal serum biomarkers and repeat transvaginal ultrasound (TVS) examinations in order to avoid delaying this diagnosis. These follow-up tests are associated with substantial financial cost to the healthcare system, as well as impacting on maternal anxiety. However, the majority of women with a PUL at follow-up will either have an intra-uterine pregnancy or a spontaneously resolving PUL, and therefore represent low-risk PULs. Most of these low-risk PULs do not need intervention and expectant management has been shown to be safe and not associated with adverse outcomes. Therefore we need consider whether the current strategies to determine pregnancy location are indeed essential for women with a PUL, especially when balancing the additional health care burden with the potential increase in maternal morbidity/mortality associated with delay in diagnosis. This beckons the question, "Do we really need to definitively diagnose pregnancy location in women with a PUL?
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Affiliation(s)
- Shannon Reid
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia.
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Rubal L, Chung K. Do you need to definitively diagnose the location of a pregnancy of unknown location? The case for "yes". Fertil Steril 2013; 98:1078-84. [PMID: 23084009 DOI: 10.1016/j.fertnstert.2012.09.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 09/17/2012] [Accepted: 09/20/2012] [Indexed: 12/27/2022]
Abstract
Pregnancy of unknown location (PUL) is a common diagnostic challenge. The primary diagnostic goal is to ensure that the PUL is nonviable prior to proceeding with any invasive procedures. In nonviable PUL, there are several diagnostic and treatment strategies, which are generally quite safe. However, the management option that provides the most definite diagnosis is uterine curettage. We advocate use of uterine curettage in all cases of nonviable PUL because it limits exposure to a chemotherapeutic agent to only those who need it and it allows for the most accurate information for counseling the patient on prognosis of future pregnancies.
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Affiliation(s)
- Lauren Rubal
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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When is a pregnancy nonviable and what criteria should be used to define miscarriage? Fertil Steril 2013; 98:1091-6. [PMID: 23084011 DOI: 10.1016/j.fertnstert.2012.09.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 09/14/2012] [Accepted: 09/17/2012] [Indexed: 11/23/2022]
Abstract
In 2011, the first systematic review of the evidence behind the diagnostic criteria for miscarriage was published. It states, "findings were limited by the small number and poor quality of the studies," and concluded that further studies were, "urgently required before setting future standards for the accurate diagnosis of early embryonic demise." This implies that data used to define criteria to diagnose miscarriage are unreliable. The 2011 Irish Health Service executive review into miscarriage misdiagnosis highlighted this issue. In parallel to these publications a multicenter prospective study was published examining cut-off values for mean sac diameter (MSD) and embryo size to define miscarriage. The authors also published evidence on expected findings when ultrasonography is repeated at an interval. This led to guidance on diagnostic criteria for miscarriage in the UK changing. These new criteria state miscarriage be considered only when: an empty gestation sac has an MSD of ≥ 25 mm (with no obvious yolk sac), or embryonic crown rump length ≥ 7 mm (the latter without evidence of fetal heart activity). If in doubt, repeating scans at an interval is emphasized. It is axiomatic that decisions about embryonic viability must not be open to doubt. So it is surprising how little evidence exists to support previous guidance. Any clinician working in this area knows of women being wrongly informed that their pregnancy has failed. This cannot be acceptable and guidance in this area must be "failsafe."
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van Mello N, Mol F, Opmeer B, Ankum W, Barnhart K, Coomarasamy A, Mol B, van der Veen F, Hajenius P. Diagnostic value of serum hCG on the outcome of pregnancy of unknown location: a systematic review and meta-analysis. Hum Reprod Update 2012; 18:603-17. [DOI: 10.1093/humupd/dms035] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hahn SA, Lavonas EJ, Mace SE, Napoli AM, Fesmire FM. Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2012; 60:381-90.e28. [DOI: 10.1016/j.annemergmed.2012.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Chen ZY, Liu JH, Liang K, Liang WX, Ma SH, Zeng GJ, Xiao SY, He JG. The diagnostic value of a multivariate logistic regression analysis model with transvaginal power Doppler ultrasonography for the prediction of ectopic pregnancy. J Int Med Res 2012; 40:184-93. [PMID: 22429358 DOI: 10.1177/147323001204000119] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A multivariate logistic regression analysis model for predicting ectopic pregnancy in women with pregnancy of unknown location was designed and evaluated clinically. METHODS Endometrial thickness, symmetry, resonance, pattern of echogenicity, helicine artery blood flow and blood flow resistance index (RI) in 129 patients with suspected early ectopic pregnancy were assessed by transvaginal power Doppler ultrasonography. Variables significant in univariate logistic regression analysis were included in a multivariate predictive logistic regression analysis model. RESULTS The final predictive model included three factors: endometrial thickness≤9 mm; a multilayered endometrial echogenicity pattern with prominent outer and midline hyperechogenic lines and an inner hypoechogenic region; and visible endometrial arterial blood flow. The area under the receiver operating characteristic curve of the model was 0.980. When RI was >0.65 and the predictive probability>0.50, diagnostic accuracy was high. The model correctly diagnosed 52/55 (94.5%) clinically confirmed ectopic pregnancy cases. CONCLUSION This multivariate predictive logistic regression analysis model has clinical value for the differential diagnosis of early ectopic pregnancy when the pregnancy location is unknown.
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Affiliation(s)
- Z-Y Chen
- Department of Medical Ultrasound, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Reid S, Casikar I, Barnhart K, Condous G. Serum biomarkers for ectopic pregnancy diagnosis. ACTA ACUST UNITED AC 2012; 6:153-65. [DOI: 10.1517/17530059.2012.664130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cong Q, Li G, Jiang W, Li B, Wang Y, Yao L, Wang S, Xu C. Ectopic choriocarcinoma masquerading as a persisting pregnancy of unknown location: case report and review of the literature. J Clin Oncol 2011; 29:e845-8. [PMID: 22042964 DOI: 10.1200/jco.2011.37.1096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Qing Cong
- Obstetrics and Gynecology Hospital, Shanghai Medical School, China
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Abstract
The term "pregnancy of unknown location" is an ultrasound classification and not a final diagnosis. The use of this terminology is here to stay and should continue as long as there is an appreciation for what it really means. It is the responsibility of the clinician, who follows up these women with a PUL, to ensure that a final diagnosis is achieved while preserving the well-being of these women.
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Affiliation(s)
- George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit Sydney Medical School Nepean, University of Sydney, Nepean Hospital Penrith, Sydney New South Wales 2750 Australia
| | - Simon Winder
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit Sydney Medical School Nepean, University of Sydney, Nepean Hospital Penrith, Sydney New South Wales 2750 Australia
| | - Shannon Reid
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit Sydney Medical School Nepean, University of Sydney, Nepean Hospital Penrith, Sydney New South Wales 2750 Australia
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