The history of the diagnosis and treatment of ectopic pregnancy: a medical adventure

Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series

A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management.

Ruptured ovarian ectopic pregnancy presenting with an acute abdomen

An ectopic pregnancy occurs in 2% of all pregnancies. A primary ovarian ectopic (OP) is a rare entity and occurs in <2% of all ectopic gestations. It may present in those individuals who take ovulatory drugs, use an intrauterine device or have undergone in vitro fertilisation or embryo transfer. Multiparity and a younger age are other recognised risk factors. Diagnosing an OP pregnancy remains a challenge and it may be misdiagnosed as a bleeding luteal cyst, a haemorrhagic ovarian cyst or a tubal pregnancy by ultrasound scan. The diagnosis is often only established at laparoscopy following histopathological examination. A ruptured OP is a potentially life-threatening condition due to its potential for haemorrhage and hemodynamic collapse. Hence, early diagnosis is crucial to prevent serious morbidity and mortality. The authors present the case of a multiparous woman in her late 30s presenting with a seizure and lower abdominal pain at 6 weeks gestation. Her beta human chorionic gonadotropin was >9000 Miu/mL. A transvaginal ultrasound scan showed no evidence of an intrauterine pregnancy. There was free fluid in the pelvis. She was hemodynamically stable. She underwent a diagnostic laparoscopy, which showed hemoperitoneum and a ruptured left OP pregnancy. She underwent a left oophorectomy. Histology confirmed chorionic villi within the ovarian stroma. This case demonstrates the challenges in preoperative diagnosis of a ruptured OP pregnancy and acts as a cautionary reminder that individuals can present with hemodynamic stability. Rarely, as in this case, an OP pregnancy can occur without the presence of risk factors. Despite its rarity, a ruptured OP pregnancy should be considered in the differential diagnosis of women of reproductive age presenting to the emergency department with acute abdominal pain and a positive pregnancy test.

Rupture of Ectopic Ovarian Pregnancy Accompanied by Massive Intra-abdominal Bleeding and Disorder of the Coagulation Mechanism: A Rare and Life-Threatening Obstetric Complication

The rupture of ectopic ovarian pregnancy accompanied by massive intra-abdominal bleeding is a rare obstetric complication, occurs predominantly in the first trimester of pregnancy, and can be dangerous and life-threatening for the pregnant woman. Our case describes a 37yr old woman with a history of 4 lower segment Cesarian sections (LSCS) (Caesarean sections) and multiple surgical abortions, presenting at the ER with acute abdomen symptoms. The patient's hemodynamic status was unstable. The positive urine pregnancy test combined with the clinical and ultrasound findings established the diagnosis of the ruptured ectopic pregnancy, and immediate surgical treatment was decided. During surgery, a large amount of blood was found in the peritoneal cavity, resulting from a rupture of the right ovary and accompanied by hemorrhagic infiltration of adjacent tissues, without participation in the damage of the ipsilateral fallopian tube. It was deemed necessary to remove the ipsilateral adnexa and whole blood transfusion. The patient was discharged from our department on the fourth postoperative day. The price of beta-chorionic gonadotropic hormone was on a downward trend. Three weeks later, the level of beta-chorionic gonadotropic hormone was zero. In the present paper, a brief review is attempted regarding the diagnostic and therapeutic approach for patients with ruptured ectopic ovarian pregnancy after describing the case.

Diagnosis and management of ectopic ovarian pregnancy: a rare case report

INTRODUCTION

Ovarian pregnancy is a rare form of ectopic pregnancy. Its incidence is 0.5% to 1% of all ectopic gestations, or 1 in 7000 to 40,000 live births. The diagnosis is intricate and based on surgical and histopathological observations. Traditional risk factors for ovarian ectopic pregnancy are similar to those for tubal pregnancy, but use of an IUD seems to be disproportionately associated.

CASE REPORT

We report a rare case of spontaneous ectopic ovarian pregnancy of a 40-year-old woman, diagnosed with a ovarian pregnancy by ultrasound and treated by laparotomy in emergency obstetrical department of Ibn Rochd University Hospital of Casablanca.

CLINICAL DISCUSSION

Ovarian ectopic pregnancies occur through fertilization of an egg retained in the peritoneal cavity leading to implantation on the surface of the ovary. The increased incidence of ovarian ectopic pregnancies is associated with the increased use of artificial reproductive technologies (ART) and intrauterine contraceptive devices (IUCDs). The diagnosis is difficult and a constant challenge for the gynecologist. Its management remains surgical therapy despite the progress in medical treatment.

CONCLUSION

Ovarian pregnancy is a rare entity that has some special features. Its diagnosis is difficult and relies on criteria based on intraoperative findings. Its management remains surgical therapy despite the progress in medical treatment.

Ovarian ectopic pregnancy after in vitro fertilisation treated by laparoscopic excision with ovarian preservation

A 42-year-old woman presented with lower abdominal pain and fainting episodes 36 days after in vitro fertilisation and embryo transfer. Transvaginal ultrasound revealed a large amount of free fluid in the pouch of Douglas and no evidence of an intrauterine gestational sac or adnexal mass suggestive of ectopic pregnancy. A presumed haemorrhagic corpus luteal cyst was seen in the left ovary. Laparoscopic exploration revealed a left ovarian haemorrhagic mass, which was excised with preservation of the ovary. Histopathological examination confirmed an ovarian ectopic pregnancy (OEP). OEP is rare but potentially life-threatening, as it can lead to internal haemorrhage. Its diagnosis is challenging as preoperative and intraoperative findings can be evocative of the far more frequent haemorrhagic corpus luteal cyst and histopathology is often necessary to confirm the diagnosis. Early recognition of OEP is crucial to reduce maternal morbidity and mortality, and allow treatment that preserves fertility as much as possible.

Outcome of methotrexate treatment for ectopic pregnancies among obese women

OBJECTIVE

Single dose administration of methotrexate (MTX) is considered the first line of treatment in selected patients with an ectopic pregnancy (EP). However, data regarding MTX efficacy among obese patients is limited. We sought to investigate the efficacy of MTX single dose regimen among obese patients MATERIAL AND METHODS: A retrospective cohort study conducted at a gynecology department in a tertiary teaching hospital, between January 2010 and December 2018, including women diagnosed with an EP and treated by a single-dose regimen of MTX. We compared success rate and gestation characteristics between obese and non-obese women.

RESULTS

Overall, 195 women were treated with single-dose intramuscular MTX for EP during the study period. Of those, 31 women (15.9%) were obese (BMI ≥ 30 kg/m2) and the rest 164 (84.1%) were of normal body weight. Median MTX dosage for the obese group was 95 milligrams (IQR 91-104) vs. 83 milligrams (IQR 78-87) for the non-obese group. Treatment success rate of the overall cohort was 66.6% (130/195) and treatment success rate of single-dose MTX was comparable between the obese and non-obese groups (64.5% vs. 67.0%, p = 0.78). Obese patients were older as compared to non-obese (median age 33 vs. 29, p = 0.03). In multivariate logistic regression analysis, percentage hCG change from day 1 to day 4 was the only factor associated with treatment success (aOR 1.02; 95%CI 1.01, 1.04, p < 0.001).

CONCLUSION

Single-dose MTX treatment among obese patients diagnosed with ectopic pregnancy led to similar success rates as compared to non-obese patients.

Evaluation of maternal serum biomarkers in predicting outcome of successful expectant management of tubal ectopic pregnancies

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.

The Unexpected Ovarian Pregnancy at Laparoscopy: A Review of Management

Ovarian ectopic pregnancies are a rare occurrence; however the incidence is on the rise. Preoperative diagnosis remains difficult due to nonspecific clinical symptoms and USS findings. Most patients undergo diagnostic laparoscopy with subsequent surgical management. We present the case of a 32-year-old female who presented with vaginal bleeding and an unsited pregnancy, with a BhCG of 24693. Formal USS described unruptured right tubal ectopic with ovarian pregnancy being diagnosed at laparoscopy. A wedge resection was conducted to preserve ovarian function. Postoperative recovery was uneventful and BhCG levels returned to zero (nonpregnant) in an outpatient setting. Although laparoscopy remains the gold standard of diagnosis and treatment, in this case report we discuss benefits of early diagnosis for fertility conserving management, including nonsurgical options.

Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy

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.

Ovarian ectopic pregnancy in adolescence

Ovarian pregnancy is one of the rarest types of extrauterine pregnancy. Its preoperative diagnosis remains a challenge since it presents quite similarly to tubal pregnancy and complicated ovarian cysts. Although in most cases, histology is necessary to confirm the diagnosis, we present an ovarian pregnancy in a teenager, correctly diagnosed during ultrasound examination.

Risk factors and clinical features of ovarian pregnancy: a case-control study

OBJECTIVE

To identify risk factors for ovarian pregnancy (OP) and compare clinical features between OP and tubal pregnancy (TP) patients.

DESIGN

Case-control study.

SETTING

University hospital.

PARTICIPANTS

A case-control study was conducted from January 2005 to May 2014. Women diagnosed with OP were recruited as the case group (n=71), 145 women with TP and 146 with intrauterine pregnancy (IUP) were matched as controls at a ratio of 1:2:2. Women who refused interviews or provided incomplete information were excluded.

RESULTS

OP risk was lower than TP risk in women with serological evidence of Chlamydia trachomatis infection (adjusted OR1 0.17, 95% CI 0.06 to 0.52), previous adnexal surgery (adjusted OR1 0.25, 95% CI 0.07 to 0.95), and current levonorgestrel emergency contraceptive use (adjusted OR1 0.24, 95% CI 0.07 to 0.78). In vitro fertilisation-embryo transfer (IVF-ET) carried a higher risk of OP (adjusted OR1 12.18, 95% CI 2.23 to 66.58) than natural conception. When Controlled by IUP women, current users of intrauterine devices (IUDs) carried a higher risk of OP than non-users of any contraceptives (adjusted OR2 9.60, 95% CI 1.76 to 42.20). β-Human chorionic gonadotropin (hCG) levels on the day of surgery were higher in OP patients than in TP patients (p<0.01). Women with OP were less likely to initially present with vaginal bleeding than those with TP (p=0.02). Moreover, shock (p=0.02), rupture (p<0.01), haemoperitoneum (p<0.01) and emergency laparotomy (p<0.01) were more common in the OP group than in the TP group.

CONCLUSIONS

IVF-ET and IUD use may be risk factors for OP, and OP patients tend to have high β-hCG levels and a poor clinical outcome (shock, rupture, haemoperitoneum and need for emergency laparotomy). Our findings may contribute to the prevention and early diagnosis of OP.

[Ectopic pregnancy: Its current interest in Primary Health Care]

An ectopic pregnancy is the implantation and development of the ovum fertilized outside the endometrial cavity. Its incidence has increased in the last 30 years, and although its morbimortality has decreased, it is still the first cause of mortality in the first trimester of the pregnancy. Early suspicion is important, particularly in women of fertile age and with risk factors indicative of an extrauterine gestation. The symptomatology is usually amenorrhea, abdominal pain, metrorrhagia, general pregnancy symptoms, and even syncope and shock. The diagnosis of ectopic pregnancy is based on the clinical information, analytical results on mother blood and urine, ultrasound examination, transvaginal culdocentesis, laparoscopic or laparotomic inspection, and a histological study. The treatment can be surgical (salpingostomy or salpingectomy), medical (methotrexate) or expectant, depending on the factors of the ectopic pregnancy: early diagnosis, presence of acute complications, clinical condition of the patient, etc.

Omental pregnancy: case report and review of literature

Pregnancy, the implantation of a fertilized ovum outside the endometrial cavity, occurs in 1.5%-2% of pregnancies. It is one of the major causes (about 6%) of maternal death during the first trimester of pregnancy. The remaining 5% implant in the ovary, peritoneal cavity, within the cervix, and the omental pregnancy is the least common form of abdominal pregnancies. A review of the literature on Medline for the period 1958-2012 reported only 16 cases of omental pregnancy. Here we report a case of primary omental pregnancy in a nulliparous woman. A 24 year-old woman gravid 1, para 0, with lower abdominal pain. Her last menstrual period occurred 8 weeks before the visit. The physical examination revealed abdominal tenderness in the lower quadrants, she was not bleeding. Transvaginal ultrasound showed: a free anechoic/hypoechoic area of 30 x 57 mm in the pouch of Douglas and the endometrium was homogeneus with a thickness of 12 mm and no evidence of gestational sac in the uterine cavity. Laboratory data revealed a normal cell blood count and beta hcg levels of 8047 IU / L. Because of continuing abdominal pain and a diagnosis of ectopic pregnancy a diagnostic laparoscopy was performed, which showed hemoperitoneum. Further inspection of abdominal cavity revealed a bloody lesion that was tenaciously adherent to the omentum, using non traumatic laparoscopic forceps and bipolar scissors we carefully removed a friable mass of about 30 mm from the omental attachments. Histological examination showed the presence of blood clot material mixed with trophoblastic tissue. Ultrasound evaluation and and hCG assessment are important to determine the extrauterine location of the ectopic pregnancy but the early diagnosis of abdominal pregnancy requires also a laparoscopic evaluation and, as our case has highlighted, thorough abdominal exploration especially in the absence of adnexal findings when ectopic pregnancy is highly suspected. Early diagnosis of omental pregnancy is difficult but essential to reduce the high mortality risk for the mother.

Primary ovarian pregnancy and its management

The authors suggest that with ultrasonographic advances, the diagnosis of primary ovarian pregnancy can be made earlier enough for conservative treatment and preservative surgery.

Primary ovarian ectopic pregnancy, i.e., the implantation of the gestational sac in the ovary, is one of the rarest forms of ectopic pregnancy. Its incidence after natural conception ranges from 1 in 2000 to 1 in 60 000 deliveries and accounts for 3% of all ectopic pregnancies. The diagnosis is intricate and based on surgical and histopathological observations. The management is, in spite of medical improvement, based on surgery.

We present a case of a 10-wk ectopic ovarian pregnancy managed laparoscopically, and we describe, through a review of the literature, the specific symptomatology, diagnostic criteria, and treatment of this particular pathology.

Ectopic pregnancy: how the diagnostic and therapeutic management has changed

Nowadays ectopic pregnancy often can be diagnosed before the woman's condition has deteriorated, which has altered the former clinical picture of a life-threatening disease into a more benign condition. This review describes the historical developments in the diagnostic and therapeutic management of ectopic pregnancy leading up to current clinical practice. The first attempts to diagnose ectopic pregnancy originate from the beginning of the 20th century.

Twenty-one years of experience with ovarian ectopic pregnancy at one institution in Taiwan

OBJECTIVE

To review the experience with patients with ovarian ectopic pregnancy (OEP) at Chang Gung Memorial Hospital, Lin-Kou Medical Center, Tao-Yuan, Taiwan, between 1989 and 2009.

METHODS

A retrospective review of the presentation, prevalence, diagnosis, and trends in treatment of patients with OEP, and the use of assisted reproductive technology (ART) procedures and intrauterine devices (IUD). The incidence rate ratios (IRR) of ectopic pregnancies (EPs) per live births, OEPs per EPs, and OEPs per live births were analyzed.

RESULTS

The 110 OEPs diagnosed comprised 2.0% of all EPs (n=5408) and 1:1543 of all live births, leading to a mean OEP per year of 5.24. Seventy-eight patients were managed with laparoscopy and 32 underwent laparotomy. Twenty-six (23.6%) patients used an IUD and 12 (10.9%) had undergone ART. OEP associated with ART increased in the last 10 years of the study period. The IRR of EPs per live births, OEPs per EPs, and OEPs per live births all increased between 1989 and 2009. Management of OEP tended to favor laparoscopy in the later years.

CONCLUSION

There was a trend toward better management of OEP with laparoscopy. ART has become a risk factor for OEP. The IRR of EPs per live births, OEPs per EPs, and OEPs per live births all increased over the 21-year period.

The evolution of methotrexate as a treatment for ectopic pregnancy and gestational trophoblastic neoplasia: a review

Methotrexate was developed in 1949 as a synthetic folic acid analogue to compete with folic acid and thus interfere with cell replication. While initially developed as a potential treatment for acute lymphoblastic leukaemia, a serendipitous observation led to methotrexate's use to effect the dramatic cure of a case of advanced choriocarcinoma. This prompted the exploration for the potential of methotrexate to treat other conditions involving disordered trophoblastic tissue. Methotrexate has subsequently revolutionized the treatment of two pregnancy-related conditions—gestational trophoblastic neoplasia and ectopic pregnancy. This article reviews the development of modern treatment protocols that use methotrexate to medically treat these two important gynaecological conditions.

Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature

We sought to determine the outcome of the laparoscopic management of ovarian ectopic pregnancy (OEP) in a United Kingdom district general hospital and reviewed the literature. We conducted a 5-year prospective cohort study of the management of OEP cases between January 2003 and January 2008. Twelve patients had OEP confirmed with histology among a cohort of 421 ectopic pregnancies. The mean gestational age was 45 days. All 12 patients had abdominal pain and 4 (33%) had vaginal bleeding. One (8%) patient became hypovolemic before laparoscopy. Four (33%) women had risk factors for ectopic pregnancy, 2 of whom were current intra-uterine contraceptive users. Preoperative diagnosis of ectopic pregnancy was made in 11 (92%) of 12 patients by transvaginal ultrasonography and OEP in 9 (75%) patients. All cases were managed by laparoscopic surgery with no conversion to laparotomy. The ovarian pregnancy was resected and the ovary conserved in 11 (92%) patients with only 1 requiring an oophorectomy. The mean operating time was 49 minutes. None of the patients needed further treatment. No complications occurred after laparoscopic surgery and the mean hospital stay was 2 days. Considering the rarity of ovarian pregnancy, this is one of the largest series of patients with OEP treated exclusively by laparoscopic surgery and highlights our recent experience of performing conservative laparoscopic surgery for most of our patients.

Extrauterine pregnancy: a historical review(3)

This article reviews historical developments in the recognition and management of abdominal and ectopic pregnancy since these entities were first recognized centuries ago. Contributions of the early anatomists who studied the female reproductive system and the courage of early surgeons who dared invade the abdomen cleared the path for the extraordinary success of today's obstetricians and gynecologists in the treatment of conditions formerly fatal to both mother and fetus.

Conservative medical and surgical management of interstitial ectopic pregnancy

OBJECTIVE

To review the definition and diagnosis of interstitial and heterotopic interstitial pregnancy and to evaluate the conservative management of these conditions.

DESIGN

A MEDLINE computer search was used to identify relevant studies. The mean values for the duration of amenorrhea, serum beta-hCG level, size of the ectopic mass, and success rates of the various treatment modalities were calculated from the raw data in the original publications.

RESULT(S)

A review of 41 patients with interstitial pregnancy who were treated with methotrexate systemically, locally, or in combination revealed an overall success rate of 83%. The mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 15,127 mIU/mL, and 23 mm, respectively. Among 22 patients with interstitial pregnancy who were treated with conservative laparoscopic techniques, the overall success rate was 100%. In this group, the mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 7,572 mIU/mL, and 31 mm, respectively. There were nine cases of heterotopic interstitial pregnancy. Seven patients were managed with potassium chloride injected into the ectopic pregnancy, and two patients were treated by laparoscopy. Overall, 67% of the coexisting intrauterine pregnancies resulted in successful deliveries and the remainder ended in spontaneous abortions.

CONCLUSION(S)

Cornual resection or hysterectomy with a laparotomy should no longer be the first line of treatment for a hemodynamically stable patient with an interstitial pregnancy. In selected cases, methotrexate and laparoscopy can be used successfully in treating early interstitial pregnancy.

Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy?

There is a widespread belief that salpingostomy is the treatment of choice for ectopic pregnancy. The ability to treat most ectopic pregnancies via a laparoscopic approach has been a major advance in gynaecological surgery. Despite the well publicized benefits of laparoscopy over laparotomy only 50% of patients with ectopic pregnancies in Australia presently benefit from this surgical advance. Although it is clear that laparoscopic treatments are preferable to laparotomy there is no consensus on whether salpingectomy or salpingostomy should be performed, despite over 40 years of research since the introduction of conservative tubal treatment. A systematic review of laparoscopic surgical treatment is needed and could be incorporated into the Cochrane Collaboration. A prospective clinical study, with long-term follow-up, needs to be performed to evaluate fertility prognosis and complications after laparoscopic salpingectomy versus salpingostomy.

A biocultural analysis of circumcision

The phenomenon of circumcision may well serve a range of religious and symbolic functions. In addition to these conceptual categories, we argue that circumcision also serves a more mundane, practical function of lowering excitability and distractibility quotients--sexual arousal--of pubescent males, i.e., biasing young males more toward increased tractability which would enhance group efforts and less toward individual goals of amorous exchanges. Neurological data suggest that early lesions of the prepuce/foreskin tissues would generate a re-organization/atrophy of the brain circuitry. This re-organization/atrophy, in turn, is suggested to lower sexual excitability. Epithelial data indicate that keratinization of the more exposed glans penis would lower the sensibility, hence sexual excitability, of the circumcised male's genitalia. In addition, circumcision removes the foreskin-prepuce which, by secreting smegma, would also minimize any pheromonic qualities which the smegma may generate. Inferential data support the hypothesis that a practical consequence of circumcision, complementary to any religious-symbolic function, is to make a circumcised male less sexually excitable and distractible, and, hence, more amenable to his group's authority figures.

Expectant management of suspected ectopic pregnancies even with rising beta-subunit human chorionic gonadotropin levels. A clinical prospective study

A prospective study was undertaken to evaluate possibility of expectant management of ectopic pregnancy in a selected group of patients with few symptoms, no gestational sac on sonography, and rising but low beta hCG levels. Using the above mentioned criteria, 26 patients were enrolled during prospective study period of 24 month. Five patients (19.2%) had a ruptured tubal pregnancy during the period of observation. Ten patients (38.5%) underwent laparoscopy with subsequent surgery for tubal pregnancy. The indication for laparoscopy in all 10 cases was abdominal pain. In all these 10 patients the pregnancy was unruptured. The remaining 11 patients (42.3%) escaped surgical intervention. Three had intrauterine pregnancies. In the remaining 8 patients the diagnosis remained presumed ectopic. The mean interval from admission of beta hCG level of < 5 mIU/ml in these 8 patients was 19.2 +/- 8.4 days. They were inpatients until the beta hCG level begun to decline. Thereafter, the patients were observed as outpatients. We conclude that in carefully selected cases of suspected ectopic pregnancies with rising but low beta hCG levels, expectant management is appropriate as long as the patient remains relatively asymptomatic.

Declining beta-human chorionic gonadotropin level may provide false security that tubal pregnancy will not rupture

Two patients with declining serum concentrations of beta-human chorionic gonadotropin (beta-hCG) and a ruptured tubal pregnancy with hemoperitoneum are described. Declining beta-hCG does not rule out the possibility that the ectopic pregnancy will rupture.