Ectopic pregnancy--an analysis of the etiology, diagnosis and treatment in 552 cases

Endometriosis diagnosis, staging and typology and adverse pregnancy outcome history

BACKGROUND

Women with endometriosis may have an increased risk of adverse pregnancy outcomes. Research has focused on infertility clinic populations limiting generalisability. Few studies report differences by endometriosis severity.

OBJECTIVES

We investigated the relationships between endometriosis diagnosis, staging and typology and pregnancy outcomes among an operative and population-based sample of women.

METHODS

Menstruating women ages 18-44 years enrolled in the ENDO Study (2007-2009), including the operative cohort: 316 gravid women undergoing laparoscopy/laparotomy at surgical centres in Utah and California; and the population cohort: 76 gravid women from the surgical centres' geographic catchment areas. Pregnancy outcomes were ascertained by questionnaire and included all pregnancies prior to study enrolment. Endometriosis was diagnosed via surgical visualisation in the operative cohort and pelvic magnetic resonance imaging in the population cohort. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated using generalised linear mixed models for pregnancy outcomes, adjusting for women's age at study enrolment and at pregnancy, surgical site, body mass index and lifestyle factors.

RESULTS

Women in the operative cohort with visualised endometriosis (n = 109, 34%) had a lower prevalence of live births, aPR 0.94 (95% CI 0.85, 1.03) and a higher prevalence of miscarriages, aPR 1.48 (95% CI 1.23, 1.77) compared with women without endometriosis. The direction and magnitude of estimates were similar in the population cohort. Women with deep endometriosis were 2.98-fold more likely (95% CI 1.12, 7.95) to report a miscarriage compared with women without endometriosis after adjusting for women's age at study enrolment and at pregnancy, surgical site and body mass index. No differences were seen between endometriosis staging and pregnancy outcomes.

CONCLUSIONS

While there was no difference in number of pregnancies among women with and without endometriosis in a population-based sample, pregnancy loss was more common among women with endometriosis, notably among those with deep endometriosis.

Ovarian pregnancy rupture in second trimester manifesting mental change in pregnancy: a case report

Ovarian pregnancies comprise approximately 3% of ectopic pregnancies. Moreover, ovarian pregnancies in the second trimester are extremely rare. We herein present a case of ruptured ovarian pregnancy in the second trimester. A 26-year-old Asian woman presented to our hospital complaining of an abrupt mental change. She was pregnant; however, she had not been receiving antenatal care. Her initial vital signs were unstable, and pelvic ultrasound revealed pelvic fluid collection. We analyzed the hemoperitoneum and performed exploratory laparotomy. When her abdomen was opened, we observed that her right ovary was ruptured. Placental cord insertion originated from the ovary, and a fetus was found in the pelvic cavity. The ovarian pregnancy was detected in a delayed state. Pregnant women require appropriate antenatal care, and pelvic ultrasound should be performed in the second trimester to ensure that the fetus is in the intrauterine cavity.

A ten year survey of 193 ectopic pregnancies

During the period 1977-86, 193 women underwent surgery for ectopic pregnancy in the Medway Health District. 1 ectopic pregnancy was found for every 233 deliveries, an incidence of 0.43%, with a rising trend. The most common presenting symptom was abdominal pain (96%) and the most frequent physical finding was abdominal tenderness (91%). Past histories of appendicectomy (24%), infertility (19%), use of IUD (15%), and pelvic infection (13%) were elicited. In 95% of the cases, the pregnancy was tubal. 56% of the patients required blood transfusions and there were no maternal deaths. These findings confirm the rising incidence of ectopic pregnancy. During the study period, the diagnosis and management of ectopic pregnancy have changed significantly. The early use of plasma hCG, ultrasonography, and laparoscopy decreases the morbidity and mortality associated with ectopic pregnancy, allowing conservative tubal surgery when indicated.

Development of dual-enzyme-based simultaneous immunoassay for measurement of progesterone and human chorionic gonadotropin

The development of a simultaneous multianalyte immunoassay for the detection of progesterone and human chorionic gonadotropin (hCG) in serum is described. In this simultaneous multianalyte assay, two different enzymes, viz. horse radish peroxidase (HRP) and alkaline phosphatase (ALP), were used as markers. To the simultaneous immobilized progesterone and hCG antibody microwells, 50 microL of different concentrations of combined standards or serum samples was added in duplicate and then 100 microL of combined conjugate reagent, composed of 17-alpha-OH-P-ALP and hCG-biotin was added to all the wells and incubated for 1h at 37 degrees C. After incubation, the contents of the wells were decanted and washed thoroughly with running tap water. After washing, 100 microL alkaline phosphatase substrate along with streptavidin-horseradish peroxidase was added to all the wells and incubated for 0.5 h at 37 degrees C. After incubation, the developed color was measured at 405 nm. The absorbency at this stage provides the result for the progesterone assay. The contents of the wells were decanted and washed. In the next step, 100 microL of tetramethylbenzidene/H2O2 reagent was added to all the wells. After 15 min of incubation, 100 microL of 0.5 M H2SO4 was added to all the wells and the color was read at 450 nm. The absorbency at this stage provides the result for the hCG assay. Sensitivity of the progesterone and hCG assays were 0.118 ng/ml and 0.124 IU/ml respectively. Intra- and inter assay percentage coefficients of variation ranged from 1.8 to 7.1 and 9.1 to 11.5 for progesterone and from 2.1 to 10.4 and 7.2 to 11.3 for hCG. There was good correlation between the discrete and the simultaneous assays. For progesterone assay, R2 was 0.99 and for hCG R2 was also 0.99. The developed dual assay for progesterone and hCG may be useful for the diagnosis of abnormal pregnancies such as miscarriages and ectopic pregnancies.

Maternal morbidity in developing countries: A review and comments

The incidence and prevalence of postpartum maternal morbidity in developing countries are poorly understood. Methodologic problems, such as lack of standard definitions, misclassification of illnesses, use of nonrepresentative samples, and inadequate validation for self-reported data, tend to compromise existing studies. Available data suggest that serious acute illnesses are common, affecting as many as 20% of mothers who deliver in hospitals in some areas. Providing good antenatal and family planning services should significantly reduce acute and chronic sequelae after parturition.

Derivation of a clinical prediction model for the emergency department diagnosis of ectopic pregnancy

OBJECTIVE

To derive a clinical prediction model for estimating the pretest probability of ectopic pregnancy in ED patients with first-trimester abdominal pain or vaginal bleeding.

METHODS

All hemodynamically stable first-trimester patients presenting to the ED of a tertiary care military teaching hospital over a 14-month period with a chief complaint of abdominal pain and/or vaginal bleeding had clinical data coded prior to determining outcome. They were then followed longitudinally until a criterion standard pregnancy outcome was established.

RESULTS

Of the 486 patients enrolled, 280 (58%) had viable intrauterine pregnancies, 167 (34%) had nonviable intrauterine pregnancies, and 39 (8%) had ectopic pregnancies. Using a recursive partitioning model, a high-risk group was derived (that was separated from intermediate and low-risk groups), consisting of patients with abdominal peritoneal signs or definite cervical motion tenderness, with a sensitivity of 31% (95% CI: 17-48%), a specificity of 93% (95% CI: 90-95%), a positive likelihood ratio of 4.3, and a negative likelihood ratio of 0.74. A low-risk group, consisting of patients with either fetal heart tones or tissue at the cervical os, or the absence of pain other than midline menstrual-like cramping and lacking any pelvic tenderness, was differentiated from an intermediate-risk group, with a sensitivity of 96% (95% CI: 81-100%), a specificity of 22% (95% CI: 18-26%), a positive likelihood ratio of 1.2, and a negative likelihood ratio of 0.17.

CONCLUSION

A clinical prediction model for estimating the probability of ectopic pregnancy in ED patients has been derived. It may prove to have practical clinical application for estimating pretest probability of ectopic pregnancy as well as assisting in medical decision making when laboratory and ultrasonographic findings are nondiagnostic. Clinical application should await prospective validation in an independent sample.

Combined chemotherapy in the medical management of tubal pregnancy

The medical management of early unruptured tubal ectopic pregnancies is gaining acceptance internationally as an alternative to surgical procedures. This method has been shown to be effective and safe in properly selected cases and with adequate supervision. Most of the work however has been done using either methotrexate or prostaglandins. The present study aimed to evaluate the efficacy of a combined therapeutic regimen. The efficacy was noted to be at least as good but with fewer side-effects. The treatment was effective in 18 out of 19 cases of tubal pregnancies (94.7%). One patient complained of a gastritis which resolved with antacids. One patient experienced abdominal cramps and transient hypotension probably as a profound vagal response during tubal abortion. The median time to resolution varied directly with the initial serum beta HCG level at diagnosis. All patients who responded to the therapy described the experience as painless and viewed the treatment positively as it spared them the need for surgery and its attendant anaesthetic risks. However, we strongly recommend caution and close supervision and to keep the patient in the hospital at least for the first week of therapy.

The pathology of intra-uterine contraceptive devices

The IUCD is a simple and effective way of producing contraception without the need for patient compliance. It is not rendered ineffective by other drugs, as may be steroid contraceptives, and its side-effects, for carefully selected patients, are considered by most practitioners to be acceptably low (Van Kets et al. 1989).

Ectopic pregnancy and infertility following treatment of infertile couples: a follow-up of 929 cases

A follow-up analysis was made of 929 infertile couples, with special attention paid to ectopic pregnancy. The conception rate was 46%, and 9% of the pregnancies were ectopic. Previous ectopic pregnancy, an industrial occupation and smoking reduced the fecundity and increased the risk of ectopic pregnancy. Tubal damage as a verified reason for infertility and its treatment also increased the risk of ectopic pregnancy. Stepwise logistic regression analysis showed the strongest association with ectopic pregnancy to exist in the case of women with a previous ectopic pregnancy (9.9-fold risk) rather than women with primary infertility. Treatment of tubal damage by salpingostomy entailed a 6.0-fold risk and treatment by other methods a 2.8-fold risk. Women working in industry had a 3.5-fold risk of ectopic pregnancy compared with those in other professions.

Diagnosis and treatment of tubal pregnancy as related to risk determinants

To evaluate whether identification of 'high risk' patients for ectopic pregnancy (EP) is beneficial for early recognition and treatment, 178 cases of tubal pregnancy were analysed. Patients with 'high risk' and 'low risk' for EP were compared for diagnostic procedures, clinical features and surgical management. The 'high risk' patients presented a shorter gestational length, lower blood loss volume, a smaller size of the tubal gestation, a lower rate of tubal rupture and underwent more conservative treatment. We conclude that identification of risk determinants may be of great importance for early recognition and hence, application of the new modalities for treatment of ectopic pregnancy.

Ectopic pregnancy in adolescents: a clinical review for pediatricians

Pediatricians caring for sexually active female adolescents and young adults need to be aware of the history, symptoms, and signs of an ectopic pregnancy. A thorough history and physical examination, including the pelvic examination, as well as specific diagnostic tests such as repeated quantitative hCG measurements, and ultrasonography when indicated, are crucial to proper and early diagnosis of a nonruptured ectopic pregnancy manageable by laparoscopy. The key to early diagnosis is to include ectopic pregnancy in the differential diagnosis in any sexually active female patient who has abnormal vaginal bleeding or abdominal pain. With early diagnosis, close observation, and appropriate management, the outcome is more likely to be favorable, with minimal morbidity and risk of death.

Ectopic pregnancy and genital infections: a case-control study

This case-control study was carried out to evaluate the significance of genital infections as risk factors in ectopic pregnancy. The study population consisted of 86 consecutive patients with ectopic pregnancy and two age- and parity-matched control groups of women with normal early pregnancy; those with planned pregnancy (I; 65 pairs) and those having legal abortion (II; 51 pairs). Histories of salpingo-oophoritis in the two groups (22% against 5%, P less than 0.05), and of cervical Chlamydia trachomatis infection (9% against 0%, P less than 0.05) were more common in patients with ectopic pregnancy than in their controls with planned pregnancy; women in the control group who had undergone legal abortion did not differ from patients with ectopic pregnancy. In serological studies antibodies against Herpes simplex viruses were commoner in patients with ectopic pregnancy than in both control groups (89% against 62%, and 88% against 57%, P less than 0.001). Antibodies against cytomegalovirus were also commoner in patients with ectopic pregnancy than in controls who had had a planned pregnancy (88% against 72%, P less than 0.05). The results support the concept that gynaecological infections are among factors predisposing to ectopic pregnancies.

Radical or conservative surgery for ectopic pregnancy? A follow-up study of fertility of 323 patients

The fertility of 323 patients desiring pregnancy after operation for ectopic pregnancy was analyzed after a follow-up period of 1 to 11 years (mean 5.1 years). The conception rate was 82%. Full-term delivery was obtained in 79% of the pregnant patients and repeat ectopic pregnancy in 13%. Nulliparous women had a significantly lower (P less than 0.01) conception rate (74%) than parous women (86%). The operation method had no influence on subsequent fertility in women with an intact contralateral tube. The women with intact contralateral tubes had a significantly higher pregnancy (P less than 0.001) and full-term birth (P less than 0.01) rates (87% and 83%, respectively) but significantly lower (P less than 0.001) repeat ectopic pregnancy rate (9%) than the women with affected contralateral tube (51%, 56%, and 52%, respectively). Compared with the parous women (9%), the risk of repeat ectopic pregnancy was significantly (P less than 0.01) higher for nulliparous women (22%). Of the nulliparous women with repeat ectopic pregnancy only 16% had a full-term pregnancy.

Suspected ectopic pregnancy: ultrasound findings and hCG levels assessed by an immunofluorometric assay

One hundred suspected ectopic pregnancies were assessed by ultrasound on the basis of the following criteria: (A) viable intrauterine fetus, intrauterine pregnancy is certain; (B) intrauterine double sac or eccentric ring, intrauterine pregnancy is probable; (C) empty uterus or central ring but no adnexal mass or cul-de-sac fluid, ectopic pregnancy is possible; (D) empty uterus or central ring and an adnexal mass or cul-de-sac fluid, ectopic pregnancy is probable; (E) viable ectopic fetus, ectopic pregnancy is certain. Serum human chorionic gonadotrophin (S-hCG) was detected by an immunofluorometric assay (sensitivity 0.2 i.u./l, cut-off level 10 i.u./l). All the 51 patients in groups A and B had an intrauterine pregnancy. Normal gestational sacs were found also at S-hCG levels of less than 3600 i.u./l, the lowest level being 894 i.u./l. Ectopic pregnancy was confirmed in 29 of the 30 women in groups D and E. In the 19 women categorized into group C serial hCG assay and repeated sonography diagnosed ectopic pregnancy in 12 and miscarriage of an intrauterine pregnancy in the other seven. Ectopic pregnancy was always found when no gestational sac was seen by sonography and the hCG level was greater than 1000 i.u./l.

Ectopic pregnancy: a case-control study of aetiological risk factors

Aetiological risk factors for ectopic pregnancies were evaluated in a prospective study of 86 consecutive patients with ectopic pregnancy and two age- and parity-matched control groups of women in normal early pregnancy; those with planned pregnancy (65 pairs) and those having legal abortion (51 pairs). Compared with women with planned pregnancy, the patients with ectopic pregnancy more often had an IUD in situ, they had less frequently used hormonal contraception, and they had more legal abortions, curettages, previous ectopic pregnancies, gynaecological operations and salpingo-oophoritis. Compared with women having legal abortion, the patients with ectopic pregnancy had favoured IUD-usage, or they had been without any contraception, and they had an increased frequency of previous ectopic pregnancies. The frequency of fertility problems was also increased in patients with ectopic pregnancy. Our results show that gynaecological pelvic operations, endometrial curettage and evacuation, gynaecological infections, and usage of IUD are important risk factors for ectopic pregnancy, and that infertility seems to be a sign of this risk. In addition, the clinical characteristics of the patients with ectopic pregnancy were similar to those of the patients having legal abortion.