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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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Maheut C, Panjo H, Capmas P. Diagnostic accuracy validation study of the M6 model without initial serum progesterone (M6 NP) in triage of pregnancy of unknown location. Eur J Obstet Gynecol Reprod Biol 2024; 296:360-365. [PMID: 38552504 DOI: 10.1016/j.ejogrb.2024.03.010] [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: 08/04/2023] [Revised: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES The M6 prediction model stratifies the risk of development of ectopic pregnancy (EP) for women with pregnancy of unknown location (PUL) into low risk or high risk, using human chorionic gonadotrophin (hCG) and progesterone levels at the initial visit to a gynaecological emergency room and hCG level at 48 h. This study evaluated a second model, the M6NP model, which does not include the progesterone level at the initial visit. The main aim of this study was to validate the diagnostic accuracy of the M6NP model in a population of French women. STUDY DESIGN Between January and December 2021, all women with an hCG measurement from the gynaecological emergency department of a teaching hospital were screened for inclusion in this study. Women with a pregnancy location determined before or at the second visit were excluded. The diagnostic test was based on logistic regression of the M6NP model, with classification into two groups: high risk of EP (≥5%) and low risk of EP (<5%). The reference test was the final outcome based on clinical, biological and sonographic results: failed PUL (FPUL), intrauterine pregnancy (IUP) or EP. Diagnostic performance for risk prediction of EP, and also IUP and FPUL, was calculated. RESULTS In total, 759 women with possible PUL were identified. After screening, 341 women with PUL were included in the main analysis. Of these, 186 (54.5%) were classified as low risk, including three (1.6%) with a final outcome of EP. The remaining 155 women with PUL were classified as high risk, of whom 60 (38.7%), 66 (42.8%) and 29 (18.7%) had a final outcome of FPUL, IUP and EP, respectively. Of the 32 women with PUL with a final outcome of EP, 29 (90.6%) were classified as high risk and three (9.4%) were classified as low risk. Therefore, the performance of the M6NP model to predict EP had a negative predictive value of 98.4%, a positive predictive value of 18.7%, sensitivity of 90.6% and specificity of 59.2%. If the prediction model had been used, it is estimated that 4.5 visits per patient could have been prevented. CONCLUSION The M6NP model could be used safely in the French population for risk stratification of PUL. Its use in clinical practice should result in a substantial reduction in the number of visits to a gynaecological emergency room.
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Affiliation(s)
- Célia Maheut
- Service Gynécologie Obstétrique, CHU Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR 1018 CESP, Equipe soins primaires et prevention, Hôpital Paul Brousse, Villejuif, France; Faculté de médecine, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Henri Panjo
- INSERM UMR 1018 CESP, Equipe soins primaires et prevention, Hôpital Paul Brousse, Villejuif, France
| | - Perrine Capmas
- Service Gynécologie Obstétrique, CHU Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR 1018 CESP, Equipe soins primaires et prevention, Hôpital Paul Brousse, Villejuif, France; Faculté de médecine, Université Paris Saclay, Le Kremlin Bicêtre, France.
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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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Dooley WM, de Braud LV, Wong M, Platts S, Ross JA, Jurkovic D. Development of a single-visit protocol for the management of pregnancy of unknown location following in vitro fertilization: a retrospective study. Hum Reprod 2024; 39:509-515. [PMID: 38265302 PMCID: PMC10905500 DOI: 10.1093/humrep/deae002] [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: 06/05/2023] [Revised: 11/29/2023] [Indexed: 01/25/2024] Open
Abstract
STUDY QUESTION Can women with pregnancy of unknown location (PUL) following in vitro fertilization (IVF) be risk-stratified regarding the subsequent need for medical intervention, based on their demographic characteristics and the results of serum biochemistry at the initial visit? SUMMARY ANSWER The ratio of serum hCG to number of days from conception (hCG/C) or the initial serum hCG level at ≥5 weeks' gestation could be used to estimate the risk of women presenting with PUL following IVF and needing medical intervention during their follow-up. WHAT IS KNOWN ALREADY In women with uncertain conception dates presenting with PUL, a single serum hCG measurement cannot be used to predict the final pregnancy outcomes, thus, serial levels are mandatory to establish a correct diagnosis. Serum progesterone levels can help to risk-stratify women at their initial visit but are not accurate in those taking progesterone supplementation, such as women pregnant following IVF. STUDY DESIGN, SIZE, DURATION This was a retrospective study carried out at two specialist early pregnancy assessment units between May 2008 and January 2021. A total of 224 women met the criteria for inclusion, but 14 women did not complete the follow-up and were excluded from the study. PARTICIPANTS/MATERIALS, SETTING, METHODS We selected women who had an IVF pregnancy and presented with PUL at ≥5 weeks' gestation. MAIN RESULTS AND THE ROLE OF CHANCE A total of 30/210 (14.0%, 95% CI 9.9-19.8) women initially diagnosed with PUL required surgical intervention. The hCG/C was significantly higher in the group of women requiring an intervention compared to those who did not (P = 0.003), with an odds ratio of 3.65 (95% CI 1.49-8.89, P = 0.004). A hCG/C <4.0 was associated with a 1.9% risk of intervention, which accounted for 25.7% of the study population. A similar result was obtained by substituting hCG/C <4.0 with an initial hCG level <100 IU/l, which was associated with 2.0% risk of intervention, and accounted for 23.8% of the study population (P > 0.05). LIMITATIONS, REASONS FOR CAUTION A limitation of our study is that it is retrospective in nature, and as such, we were reliant on existing data. WIDER IMPLICATIONS OF THE FINDINGS A previous study in women with PUL after spontaneous conception found that a 2% intervention rate was considered low enough to eliminate the need for close follow-up and serial blood tests. Using the same 2% cut-off, a quarter of women with PUL after IVF could also avoid attending for further visits and investigations. STUDY FUNDING/COMPETING INTEREST(S) No external funding was required for this study. No conflicts of interest are required to be declared. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- W M Dooley
- Faculty of Population Health Sciences, Institute for Women’s Health, University College Hospital, London, UK
| | - L V de Braud
- Faculty of Population Health Sciences, Institute for Women’s Health, University College Hospital, London, UK
| | - M Wong
- Faculty of Population Health Sciences, Institute for Women’s Health, University College Hospital, London, UK
| | - S Platts
- Early Pregnancy and Gynaecology Assessment Unit, Kings College Hospital, London, UK
| | - J A Ross
- Early Pregnancy and Gynaecology Assessment Unit, Kings College Hospital, London, UK
| | - D Jurkovic
- Faculty of Population Health Sciences, Institute for Women’s Health, University College Hospital, London, UK
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Schwangerschaftsverlauf bei „pregnancy of unknown location“. GYNAKOLOGISCHE ENDOKRINOLOGIE 2022. [DOI: 10.1007/s10304-022-00455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ghaedi B, Cheng W, Ameri S, Abdulkarim K, Costain N, Zia A, Thiruganasambandamoorthy V. Performance of single serum progesterone in the evaluation of symptomatic first-trimester pregnant patients: a systematic review and meta-analysis. CAN J EMERG MED 2022; 24:611-621. [PMID: 35921048 DOI: 10.1007/s43678-022-00332-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/25/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Pain and bleeding complicate 30% of pregnancies, raising concerns for viability. The objective is to evaluate the diagnostic characteristics of a single serum progesterone level in assessing pregnancy viability among symptomatic patients. METHODS We conducted a predefined literature search in MEDLINE, Embase (OVID), CINAHL and Cochrane databases for studies that enrolled patients in first trimester with miscarriage symptoms, measured progesterone and reported pregnancy viability, from inception to July 2020. We extracted data for 2 × 2 tables, progesterone threshold levels and viability. We obtained summary estimates of sensitivity, specificity, Diagnostic Odds Ratio (DOR), and predictive values at given prevalence rates. RESULTS We identified 54 publications. There was a total of 15,878 patients enrolled, of whom 7864 patients (49.5%) were confirmed to have a viable pregnancy and 8014 patients (50.5%) were confirmed to have a non-viable pregnancy. The cut-off value of progesterone ranged from 3.2 to 25 ng/mL (20.034-79.5 nmol/L). We evaluated the performance of the following progesterone cut-off categories: < 6.3, 6.3-12.6, 12.7-19.9, and 20-25 ng/mL. To detect non-viable pregnancy, progesterone with cut-off < 6.3 ng/mL had sensitivity 73.1%, specificity 99.2% and DOR 322.0 (PPV 0.91, 0.97 and 0.99 at prevalences 0.1, 0.25, 0.5, respectively, indicating higher likelihood of non-viable pregnancy), and cut-off category 20-25 ng/mL had sensitivity 91.3%, specificity 75% and DOR 31.4 (NPV 0.99, 0.96 and 0.89 at the prevalences above indicating higher likelihood of viable pregnancy). CONCLUSION A single progesterone level provides a clinically useful prognostic information on pregnancy viability. More than nine out of ten patients with a level < 6.3 ng/mL (< 20.034 nmol/L) will be diagnosed with a non-viable pregnancy, and more than 90% of patients with a level ≥ 20-25 ng/mL (63.6-79.5 nmol/L) will have a viable pregnancy confirmed.
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Affiliation(s)
- Bahareh Ghaedi
- Department of Clinical Epidemiology Program-Emergency Medicine, Clinical Epidemiology Unit, Ottawa Hospital Research Institute, ON, Ottawa, Canada
| | - Wei Cheng
- Yale School of Public Health, New Haven, USA
| | - Sara Ameri
- Department of Clinical Epidemiology Program-Emergency Medicine, Clinical Epidemiology Unit, Ottawa Hospital Research Institute, ON, Ottawa, Canada
| | | | - Nicholas Costain
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Ayesha Zia
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Clinical Epidemiology Program-Emergency Medicine, Clinical Epidemiology Unit, Ottawa Hospital Research Institute, ON, Ottawa, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,The Ottawa Hospital, Ottawa, ON, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
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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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Christodoulou E, Bobdiwala S, Kyriacou C, Farren J, Mitchell-Jones N, Ayim F, Chohan B, Abughazza O, Guruwadahyarhalli B, Al-Memar M, Guha S, Vathanan V, Gould D, Stalder C, Wynants L, Timmerman D, Bourne T, Van Calster B. External validation of models to predict the outcome of pregnancies of unknown location: a multicentre cohort study. BJOG 2020; 128:552-562. [PMID: 32931087 PMCID: PMC7821217 DOI: 10.1111/1471-0528.16497] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 12/23/2022]
Abstract
Objective To validate externally five approaches to predict ectopic pregnancy (EP) in pregnancies of unknown location (PUL): the M6P and M6NP risk models, the two‐step triage strategy (2ST, which incorporates M6P), the M4 risk model, and beta human chorionic gonadotropin ratio cut‐offs (BhCG‐RC). Design Secondary analysis of a prospective cohort study. Setting Eight UK early pregnancy assessment units. Population Women presenting with a PUL and BhCG >25 IU/l. Methods Women were managed using the 2ST protocol: PUL were classified as low risk of EP if presenting progesterone ≤2 nmol/l; the remaining cases returned 2 days later for triage based on M6P. EP risk ≥5% was used to classify PUL as high risk. Missing values were imputed, and predictions for the five approaches were calculated post hoc. We meta‐analysed centre‐specific results. Main outcome measures Discrimination, calibration and clinical utility (decision curve analysis) for predicting EP. Results Of 2899 eligible women, the primary analysis excluded 297 (10%) women who were lost to follow up. The area under the ROC curve for EP was 0.89 (95% CI 0.86–0.91) for M6P, 0.88 (0.86–0.90) for 2ST, 0.86 (0.83–0.88) for M6NP and 0.82 (0.78–0.85) for M4. Sensitivities for EP were 96% (M6P), 94% (2ST), 92% (N6NP), 80% (M4) and 58% (BhCG‐RC); false‐positive rates were 35%, 33%, 39%, 24% and 13%. M6P and 2ST had the best clinical utility and good overall calibration, with modest variability between centres. Conclusions 2ST and M6P performed best for prediction and triage in PUL. Tweetable abstract The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs. The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.
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Affiliation(s)
- E Christodoulou
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - S Bobdiwala
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - C Kyriacou
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | | | | | - F Ayim
- Hillingdon Hospital, London, UK
| | - B Chohan
- Wexham Park Hospital, Slough, UK
| | | | | | - M Al-Memar
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - S Guha
- Chelsea and Westminster NHS Trust, London, UK
| | | | - D Gould
- St Marys' Hospital, London, UK
| | - C Stalder
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - L Wynants
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, 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
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - B Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands.,EPI-Centre, KU Leuven, Leuven, Belgium
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Evaluation of maternal serum biomarkers in predicting outcome of successful expectant management of tubal ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol 2020; 250:61-65. [PMID: 32387894 DOI: 10.1016/j.ejogrb.2020.04.009] [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: 01/09/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the value of multiple serum biomarkers for the prediction of successful outcome of expectant management in women with tubal ectopic pregnancy (TEP). STUDY DESIGN Women with a conclusive ultrasound diagnosis of TEP had a blood test to measure β-human chorionic gonadotropin (β-hCG), progesterone, inhibin A, activin A and high sensitivity C-reactive protein (hsCRP) at the initial visit. Women presenting with pain, serum β-hCG ≥ 1500 IU, evidence of a live ectopic pregnancy or a significant haemoperitoneum were advised to have emergency surgery. Women eligible for expectant management were followed-up prospectively until serum β-hCG declined to non-pregnant level or surgical treatment was required. RESULTS A total of 93 women with a TEP were included in the final cohort. Emergency surgery was carried out in 42/93 (45 %) of women whilst 51/93 (55 %) were managed expectantly. Of the latter group, 42/51 (82 %) had successful expectant management and 9/51(18 %) required surgical procedure after a period of follow up. On multi-variable analysis, only higher values of serum β-hCG and progesterone at the initial visit were associated with a lower chance of successful expectant management of TEP. A one-unit increase in either variable on the log-scale was associated with an approximate 20-fold reduction in the odds of a successful outcome. CONCLUSION(S) Serum β-hCG and progesterone were significantly lower in women who had successful expectant management of TEP. Other biomarkers under consideration were not significantly different in women with successful and failed expectant management.
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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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11
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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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Van Calster B, Bobdiwala S, Guha S, Van Hoorde K, Al-Memar M, Harvey R, Farren J, Kirk E, Condous G, Sur S, Stalder C, Timmerman D, Bourne T. Managing pregnancy of unknown location based on initial serum progesterone and serial serum hCG levels: development and validation of a two-step triage protocol. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:642-649. [PMID: 26776599 DOI: 10.1002/uog.15864] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/08/2016] [Accepted: 01/11/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES A uniform rationalized management protocol for pregnancies of unknown location (PUL) is lacking. We developed a two-step triage protocol to select PUL at high risk of ectopic pregnancy (EP), based on serum progesterone level at presentation (step 1) and the serum human chorionic gonadotropin (hCG) ratio, defined as the ratio of hCG at 48 h to hCG at presentation (step 2). METHODS This was a cohort study of 2753 PUL (301 EP), involving a secondary analysis of prospectively and consecutively collected PUL data from two London-based university teaching hospitals. Using a chronological split we used 1449 PUL for development and 1304 for validation. We aimed to assign PUL as low risk with high confidence (high negative predictive value (NPV)) while classifying most EP as high risk (high sensitivity). The first triage step assigned PUL as low risk using a threshold of serum progesterone at presentation. The remaining PUL were triaged using a novel logistic regression risk model based on hCG ratio and initial serum progesterone (second step), defining low risk as an estimated EP risk of < 5%. RESULTS On validation, initial serum progesterone ≤ 2 nmol/L (step 1) classified 16.1% PUL as low risk. Second-step classification with the risk model selected an additional 46.0% of all PUL as low risk. Overall, the two-step protocol classified 62.1% of PUL as low risk, with an NPV of 98.6% and a sensitivity of 92.0%. When the risk model was used in isolation (i.e. without the first step), 60.5% of PUL were classified as low risk with 99.1% NPV and 94.9% sensitivity. CONCLUSION PUL can be classified efficiently into being either high or low risk for complications using a two-step protocol involving initial progesterone and hCG levels and the hCG ratio. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- B Van Calster
- KU Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - S Bobdiwala
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - S Guha
- West Middlesex Hospital, Isleworth, Middlesex, UK
| | | | - M Al-Memar
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - R Harvey
- Charing Cross Oncology Laboratory and Trophoblastic Disease Center, Charing Cross Hospital, London, UK
| | - J Farren
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - E Kirk
- North Middlesex Hospital, London, UK
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Medical School, Nepean Hospital, University of Sydney, Kingswood, NSW, Australia
| | - S Sur
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - C Stalder
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
| | - D Timmerman
- KU Leuven, Department of Development and Regeneration, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - T Bourne
- KU Leuven, Department of Development and Regeneration, Leuven, Belgium
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
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Yalçin I, Taşkin S, Pabuçcu EG, Söylemez F. The value of placental protein 13, β-human chorionic gonadotropin and progesterone in the prediction of miscarriages in threatened miscarriage patients. J OBSTET GYNAECOL 2014; 35:283-6. [PMID: 25153203 DOI: 10.3109/01443615.2014.948822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this paper was to investigate the levels of maternal serum placental protein13 (PP13), beta human chorionic gonadotropin (β-hCG) and progesterone in the prediction of miscarriages in threatened miscarriages. A total of 110 patients with a gestational age < 14 weeks were included in the study. A total of 42 patients were allocated as the study group (threatened miscarriage) and 68 patients were allocated as controls. A total of six miscarriages were observed in the study group. β-hCG levels were significantly lower in the group with threatened miscarriage when compared with controls (p = 0.018). There was no statistically significant difference in regard to progesterone and PP13 levels occurred between two groups (p = 0.653 and p = 0.062, respectively). Following receiver operating characteristic (ROC) analysis, the β-hCG parameter was found useful in differentiating miscarriages from the threatened miscarriage group (p = 0.031). PP13 and progesterone parameters in predicting miscarriages were not found as statistically significant (p = 0.084 and p = 0.914, respectively). This study suggests that β-hCG measurements could be useful in predicting spontaneous miscarriage in women presenting with threatened miscarriage. Even though PP13 seems unfeasible to be used as a predictive marker for miscarriage, factors affecting PP13 levels should be considered along with the need for comprehensive studies including larger patient populations.
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Affiliation(s)
- I Yalçin
- Department of Obstetrics and Gynecology, Alaşehir State Hospital , Manisa , Turkey
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Abstract
We provide a review of microRNA (miRNA) related to human implantation which shows the potential diagnostic role of miRNAs in impaired endometrial receptivity, altered embryo development, implantation failure after assisted reproduction technology, and in ectopic pregnancy and pregnancies of unknown location. MicroRNAs may be emerging diagnostic markers and potential therapeutic tools for understanding implantation disorders. However, further research is needed before miRNAs can be used in clinical practice for identifying and treating implantation failure.
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Cut-off value of initial serum β-hCG level predicting a successful MTX therapy in tubal ectopic pregnancy: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2014; 179:175-80. [PMID: 24956362 DOI: 10.1016/j.ejogrb.2014.05.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/20/2014] [Accepted: 05/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the optimal serum β-hCG cut-off level to predict MTX treatment success in tubal ectopic pregnancy (EP). STUDY DESIGN Data of 240 women, who presented between 2003 and 2011 at the Department of Gynecology and Obstetrics, Medical University of Vienna, with tubal EP and who received MTX as primary treatment, were retrieved from the hospital information system (KIS). 198 patients could be included for final evaluation. Statistical analysis included area under the ROC curve, maximal Euclidean and Youden index, chi-squared and a five-fold cross validation. RESULTS The serum β-hCG level cut-off value was calculated at 2121mlU/ml with a specificity of 76.54% and sensitivity of 80.56% (AUC 0.789; p<0.001). Patients with an initial serum β-hCG level below 2121mlU/ml (n=131) experienced MTX treatment failure in 5.3% (n=7), compared to 43.3% (n=29) of patients with an initial serum β-hCG level equal to or above 2121mlU/ml (n=67). There was no statistically significant correlation between clinical symptoms and the MTX therapy outcome (p=0.580; likelihood quotient p=0.716). CONCLUSION The correct decision of therapy in patients with tubal ectopic pregnancy still represents a challenge. In this study we can conclude that, according to our results there is no endpoint of initial serum β-hCG levels, which can be clearly used as cut-off value for the optimal management of tubal EP. However, an initial serum β-hCG level of less than 2121mlU/ml seems to be a good value to expect a successful MTX treatment. Limitations are the retrospective study design and the inability of classifying clinical symptoms like pain as an objective parameter. Wider implications of the findings may include more detailed patient information and more accurate selection of suitable patients for MTX therapy.
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Knez J, Day A, Jurkovic D. Ultrasound imaging in the management of bleeding and pain in early pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:621-36. [PMID: 24841987 DOI: 10.1016/j.bpobgyn.2014.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/16/2014] [Accepted: 04/10/2014] [Indexed: 12/27/2022]
Abstract
Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.
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Affiliation(s)
- Jure Knez
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Andrea Day
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK.
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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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Predictive value of serum human chorionic gonadotropin ratio, progesterone and inhibin A for expectant management of early pregnancies of unknown location. Eur J Obstet Gynecol Reprod Biol 2012; 165:66-9. [DOI: 10.1016/j.ejogrb.2012.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 06/25/2012] [Accepted: 07/23/2012] [Indexed: 11/18/2022]
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Verhaegen J, Gallos ID, van Mello NM, Abdel-Aziz M, Takwoingi Y, Harb H, Deeks JJ, Mol BWJ, Coomarasamy A. Accuracy of single progesterone test to predict early pregnancy outcome in women with pain or bleeding: meta-analysis of cohort studies. BMJ 2012; 345:e6077. [PMID: 23045257 PMCID: PMC3460254 DOI: 10.1136/bmj.e6077] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the accuracy with which a single progesterone measurement in early pregnancy discriminates between viable and non-viable pregnancy. DESIGN Systematic review and meta-analysis of diagnostic accuracy studies. DATA SOURCES Medline, Embase, CINAHL, Web of Science, ProQuest, Conference Proceedings Citation Index, and the Cochrane Library from inception until April 2012, plus reference lists of relevant studies. STUDY SELECTION Studies were selected on the basis of participants (women with spontaneous pregnancy of less than 14 weeks of gestation); test (single serum progesterone measurement); outcome (viable intrauterine pregnancy, miscarriage, or ectopic pregnancy) diagnosed on the basis of combinations of pregnancy test, ultrasound scan, laparoscopy, and histological examination; design (cohort studies of test accuracy); and sufficient data being reported. RESULTS 26 cohort studies, including 9436 pregnant women, were included, consisting of 7 studies in women with symptoms and inconclusive ultrasound assessment and 19 studies in women with symptoms alone. Among women with symptoms and inconclusive ultrasound assessments, the progesterone test (5 studies with 1998 participants and cut-off values from 3.2 to 6 ng/mL) predicted a non-viable pregnancy with pooled sensitivity of 74.6% (95% confidence interval 50.6% to 89.4%), specificity of 98.4% (90.9% to 99.7%), positive likelihood ratio of 45 (7.1 to 289), and negative likelihood ratio of 0.26 (0.12 to 0.57). The median prevalence of a non-viable pregnancy was 73.2%, and the probability of a non-viable pregnancy was raised to 99.2% if the progesterone was low. For women with symptoms alone, the progesterone test had a higher specificity when a threshold of 10 ng/mL was used (9 studies with 4689 participants) and predicted a non-viable pregnancy with pooled sensitivity of 66.5% (53.6% to 77.4%), specificity of 96.3% (91.1% to 98.5%), positive likelihood ratio of 18 (7.2 to 45), and negative likelihood ratio of 0.35 (0.24 to 0.50). The probability of a non-viable pregnancy was raised from 62.9% to 96.8%. CONCLUSION A single progesterone measurement for women in early pregnancy presenting with bleeding or pain and inconclusive ultrasound assessments can rule out a viable pregnancy.
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Affiliation(s)
- Jorine Verhaegen
- Department of Obstetrics and Gynaecology, Academic Medical Centre University of Amsterdam, Amsterdam, Netherlands
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Lautmann K, Cordina M, Elson J, Johns J, Schramm-Gajraj K, Ross JA. Clinical use of a model to predict the viability of early intrauterine pregnancies when no embryo is visible on ultrasound. Hum Reprod 2011; 26:2957-63. [DOI: 10.1093/humrep/der287] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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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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Chetty M, Sawyer E, Dew T, Chapman AJ, Elson J. The use of novel biochemical markers in predicting spontaneously resolving 'pregnancies of unknown location'. Hum Reprod 2011; 26:1318-23. [DOI: 10.1093/humrep/der064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cordina M, Schramm-Gajraj K, Ross JA, Lautman K, Jurkovic D. Introduction of a single visit protocol in the management of selected patients with pregnancy of unknown location: a prospective study. BJOG 2011; 118:693-7. [DOI: 10.1111/j.1471-0528.2011.02893.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barnhart K, van Mello NM, Bourne T, Kirk E, Van Calster B, Bottomley C, Chung K, Condous G, Goldstein S, Hajenius PJ, Mol BW, Molinaro T, O'Flynn O'Brien KL, Husicka R, Sammel M, Timmerman D. Pregnancy of unknown location: a consensus statement of nomenclature, definitions, and outcome. Fertil Steril 2010; 95:857-66. [PMID: 20947073 DOI: 10.1016/j.fertnstert.2010.09.006] [Citation(s) in RCA: 191] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 06/30/2010] [Accepted: 09/03/2010] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of population, target disease, and final outcome. DESIGN A review of literature and a series of collaborative international meetings were used to develop a consensus for definitions and final outcomes of women initially diagnosed with a PUL. RESULT(S) Global differences were noted in populations studied and in the definitions of outcomes. We propose to define initial ultrasound classification of findings into five categories: definite ectopic pregnancy (EP), probable EP, PUL, probable intrauterine pregnancy (IUP), and definite IUP. Patients with a PUL should be followed and final outcomes should be categorized as visualized EP, visualized IUP, spontaneously resolved PUL, and persisting PUL. Those with the transient condition of a persisting PUL should ultimately be classified as nonvisualized EP, treated persistent PUL, resolved persistent PUL, or histologic IUP. These specific categories can be used to characterize the natural history or location (intrauterine vs. extrauterine) of any early gestation where the initial location is unknown. CONCLUSION(S) Careful definition of populations and classification of outcomes should optimize objective interpretation of research, allow objective assessment of future reproductive prognosis, and hopefully lead to improved clinical care of women initially identified to have a PUL.
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Affiliation(s)
- Kurt Barnhart
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Predictive power progesterone combined with beta human chorionic gonadotropin measurements in the outcome of threatened miscarriage. Arch Gynecol Obstet 2010; 283:431-5. [DOI: 10.1007/s00404-010-1367-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 01/12/2010] [Indexed: 10/19/2022]
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Bignardi T, Condous G. Re: Use of serum progesterone measurements to reduce need for follow-up in women with pregnancies of unknown location. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:361-363. [PMID: 19670407 DOI: 10.1002/uog.7323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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