1
|
Iqbal M, Zubair M, Saeed Awan A, Khan Y, Yasmin H, Rahim R, Srichand P, Pal SA, Mazhar SB, Sohail R, Zaman F, Ali S, Ali T. Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach. Cureus 2024; 16:e65079. [PMID: 39171060 PMCID: PMC11337146 DOI: 10.7759/cureus.65079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVE It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan. METHODS A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus. RESULTS Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion. CONCLUSION These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.
Collapse
Affiliation(s)
- Maryam Iqbal
- Obstetrics and Gynecology, Integrated Medical Care Hospital, Lahore, PAK
| | - Maryam Zubair
- Obstetrics and Gynecology, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
| | - Azra Saeed Awan
- Obstetrics and Gynecology, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Yousaf Khan
- Obstetrics and Gynecology, Hameed Latif Hospital, Lahore, PAK
| | - Haleema Yasmin
- Obstetrics and Gynecology, Jinnah Postgraduate Medical Center (JPMC), Karachi, PAK
| | - Rehana Rahim
- Obstetrics and Gynecology, Lady Ready Hospital, Peshawar, PAK
| | - Pushpa Srichand
- Obstetrics and Gynecology, Isra University Hospital, Hyderabad, PAK
| | - Sadiah A Pal
- Epidemiology, Concept Fertility Center, Karachi, PAK
| | - Syeda Batool Mazhar
- Obstetrics and Gynecology, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Rubina Sohail
- Epidemiology and Public Health, Hameed Latif Hospital, Lahore, PAK
| | - Farrukh Zaman
- Obstetrics and Gynecology, Hameed Latif Hospital, Lahore, PAK
| | - Sobia Ali
- Medical Affairs, Established Pharmaceutical Division, Abbott Laboratories (Pakistan) Limited, Karachi, PAK
| | - Tabrez Ali
- Medical Affairs, Established Pharmaceutical Division, Abbott Laboratories (Pakistan) Limited, Karachi, PAK
| |
Collapse
|
2
|
Oyeh E, Ofori S, Hiadzi EK, Sefogah PE. Challenges in the diagnosis and management of a ruptured heterotopic gestation following ultrasound-guided embryo transfer in low resource settings: a case report. J Med Case Rep 2024; 18:28. [PMID: 38263261 PMCID: PMC10807105 DOI: 10.1186/s13256-023-04317-x] [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: 05/26/2023] [Accepted: 12/12/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Heterotopic pregnancies are increasing in incidence with the advent of rising prevalence of in vitro fertilization and embryo transfer (IVF-ET) globally. Although rare, this condition is a serious potentially life-threatening gynaecological complication. CASE PRESENTATION We present the case of a 36-year-old Ghanaian woman who conceived following IVF and presented two weeks after confirmation of intrauterine gestation with sudden onset lower abdominal pain. A diagnosis of ruptured heterotopic pregnancy was made, laparotomy and salpingectomy was done followed with further management of the intrauterine gestation. CONCLUSION To the best of our knowledge, this is the first reported case of heterotopic pregnancy in Ghana. A high index of suspicion for heterotopic pregnancy is required even in the presence of a confirmed intrauterine gestation following IVF-ET.
Collapse
Affiliation(s)
- Ernest Oyeh
- Akai House Clinic, 1 Sixth Circular Rd, Accra, Ghana
| | - Samuel Ofori
- Lister Hospital and Fertility Centre, Airport Hills, Accra, Ghana
| | - Edem K Hiadzi
- Lister Hospital and Fertility Centre, Airport Hills, Accra, Ghana
| | - Promise E Sefogah
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Accra, Ghana.
| |
Collapse
|
3
|
Pape J, Bajka A, Seifert B, Asmis L, Imesch P, Metzler J, Burkhardt T, Condous G, Samartzis EP, Bajka M. Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery - The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:614-622. [PMID: 36657460 DOI: 10.1055/a-1967-2134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency. METHODS Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves. RESULTS Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794-0.879) and high urgency (AUC 0.902, 95 % CI 0.860-0.945). CONCLUSION Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.
Collapse
Affiliation(s)
- Janna Pape
- Gynecology, University Hospital Zurich, Zurich, Switzerland
- Gynecologic Endocrinology and Reproductive Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Anahita Bajka
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Lars Asmis
- Center for perioperative thrombosis and hemostasis, University of Zurich, Zurich, Switzerland
| | - Patrick Imesch
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Julian Metzler
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Tilo Burkhardt
- Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - George Condous
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, University of Sydney - Sydney Medical School Nepean, Sydney, Australia
| | - Eleftherios Pierre Samartzis
- Gynecology, University Hospital Zurich, Zurich, Switzerland
- Gynecology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Michael Bajka
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
4
|
Deffieux X, Rousset-Jablonski C, Gantois A, Brillac T, Maruani J, Maitrot-Mantelet L, Mignot S, Gaucher L, Athiel Y, Baffet H, Bailleul A, Bernard V, Bourdon M, Cardaillac C, Carneiro Y, Chariot P, Corroenne R, Dabi Y, Dahlem L, Frank S, Freyens A, Grouthier V, Hernandez I, Iraola E, Lambert M, Lauchet N, Legendre G, Le Lous M, Louis-Vahdat C, Martinat Sainte-Beuve A, Masson M, Matteo C, Pinton A, Sabbagh E, Sallee C, Thubert T, Heron I, Pizzoferrato AC, Artzner F, Tavenet A, Le Ray C, Fauconnier A. [Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:297-330. [PMID: 37258002 DOI: 10.1016/j.gofs.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To provide guidelines for the pelvic clinical exam in gynecology and obstetrics. MATERIAL AND METHODS A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature. CONCLUSIONS The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.
Collapse
Affiliation(s)
- Xavier Deffieux
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, université Paris-Saclay, AP-HP, 92140 Clamart, France.
| | - Christine Rousset-Jablonski
- Département de chirurgie, Centre Léon Bérard, 28, rue Laënnec, 69008 Lyon, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), université Claude-Bernard Lyon 1, 69008 Lyon, France; Service de Gynécologie-Obstétrique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Adrien Gantois
- Collège national des sages-femmes de France hébergé au Réseau de santé périnatal parisien (RSPP), 75010 Paris, France
| | | | - Julia Maruani
- Cabinet médical, 6, rue Docteur-Albert-Schweitzer, 13006 Marseille, France
| | - Lorraine Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris centre (HUPC), 75014 Paris, France
| | | | - Laurent Gaucher
- Collège national des sages-femmes de France, CNSF, 75010 Paris, France; Public Health Unit, hospices civils de Lyon, 69500 Bron, France; Inserm U1290, Research on Healthcare Performance (RESHAPE), université Claude-Bernard Lyon 1, 69008 Lyon, France; Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, 1206 Genève, Suisse
| | - Yoann Athiel
- Maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, université Paris cité, FHU Prema, 75014 Paris, France
| | - Hortense Baffet
- Service de gynécologie médicale, orthogénie et sexologie, CHU de Lille, université de Lille, 59000 Lille, France
| | - Alexandre Bailleul
- Service de gynécologie-obstétrique, centre hospitalier de Poissy Saint-Germain-en-Laye, 78300 Poissy, France; Équipe RISCQ « Risques cliniques et sécurité en santé des femmes et en santé périnatale », université Paris-Saclay, UVSQ, 78180 Montigny-le-Bretonneux, France
| | - Valérie Bernard
- Service de chirurgie gynécologique, gynécologie médicale et médecine de la reproduction, centre Aliénor d'Aquitaine, centre hospitalo-universitaire Pellegrin, 33000 Bordeaux, France; Unité Inserm 1312, université de Bordeaux, Bordeaux Institute of Oncology, 33000 Bordeaux, France
| | - Mathilde Bourdon
- Service de gynécologie-obstétrique II et médecine de la reproduction, université Paris cité, AP-HP, centre hospitalier universitaire (CHU) Cochin Port-Royal, 75014 Paris, France
| | - Claire Cardaillac
- Service de gynécologie-obstétrique, CHU de Nantes, 44000 Nantes, France
| | | | - Patrick Chariot
- Département de médecine légale et sociale, Assistance publique-Hôpitaux de Paris, 93140 Bondy, France; Institut de recherche interdisciplinaire sur les enjeux sociaux, UMR 8156-997, UFR SMBH, université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Romain Corroenne
- Service de gynécologue-obstétrique, CHU d'Angers, 49000 Angers, France
| | - Yohann Dabi
- Service de gynécologie-obstétrique et médecine de la reproduction, Sorbonne université-AP-HP-hôpital Tenon, 75020 Paris, France
| | - Laurence Dahlem
- Département universitaire de médecine générale, faculté de médecine, université de Bordeaux, 146, rue Léo-Saignat, 33076 Bordeaux, France
| | - Sophie Frank
- Service d'oncogénétique, Institut Curie, 75005 Paris, France
| | - Anne Freyens
- Département universitaire de médecine générale (DUMG), université Paul-Sabatier, 31000 Toulouse, France
| | - Virginie Grouthier
- Service d'endocrinologie, diabétologie, nutrition et d'endocrinologie des gonades, Hôpital Haut Lévêque, Centre Hospitalo-universitaire régional de Bordeaux, 31000 Bordeaux, France; Université de Bordeaux, Inserm U1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Isabelle Hernandez
- Collège national des sages-femmes de France hébergé au Réseau de santé périnatal parisien (RSPP), 75010 Paris, France
| | - Elisabeth Iraola
- Institut de recherche interdisciplinaire sur les enjeux sociaux (IRIS), UMR 8156-997, CNRS U997 Inserm EHESS UP13 UFR SMBH, université Sorbonne Paris Nord, Paris, France; Direction de la protection maternelle et infantile et promotion de la santé, conseil départemental du Val-de-Marne, 94000 Créteil, France
| | - Marie Lambert
- Service de chirurgie gynécologique, gynécologie médicale et médecine de la reproduction, centre Aliénor d'Aquitaine, centre hospitalo-universitaire Pellegrin, 33000 Bordeaux, France
| | - Nadege Lauchet
- Groupe médical François-Perrin, 9, rue François-Perrin, 87000 Limoges, France
| | - Guillaume Legendre
- Service de gynécologue-obstétrique, CHU Angers, 49000 Angers, France; UMR_S1085, université d'Angers, CHU d'Angers, université de Rennes, Inserm, EHESP, Irset (institut de recherche en santé, environnement et travail), Angers, France
| | - Maela Le Lous
- Université de Rennes 1, Inserm, LTSI - UMR 1099, 35000 Rennes, France; Département de gynécologie et obstétrique, CHU de Rennes, 35000 Rennes, France
| | - Christine Louis-Vahdat
- Cabinet de gynécologie et obstétrique, 126, boulevard Saint-Germain, 75006 Paris, France
| | | | - Marine Masson
- Département de médecine générale, 86000 Poitiers, France
| | - Caroline Matteo
- Ecole de maïeutique, Aix Marseille Université, 13015 Marseille, France
| | - Anne Pinton
- Service de gynécologie-obstétrique, hôpital Trousseau, AP-HP, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Sorbonne université, 75013 Paris, France
| | - Emmanuelle Sabbagh
- Unité de gynécologie médicale, hôpital Port-Royal, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris centre (HUPC), 75014 Paris, France
| | - Camille Sallee
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU de Limoges, 87000 Limoges, France
| | - Thibault Thubert
- Service de gynecologie-obstétrique, CHU de Nantes, 44000 Nantes, France; EA 4334, laboratoire mouvement, interactions, performance (MIP), Nantes université, 44322 Nantes, France
| | - Isabelle Heron
- Service d'endocrinologie, université de Rouen, hôpital Charles-Nicolle, 76000 Rouen, France; Cabinet médical, Clinique Mathilde, 76100 Rouen, France
| | - Anne-Cécile Pizzoferrato
- Service de gynécologie-obstétrique, hôpital universitaire de La Miletrie, 86000 Poitiers, France; Inserm CIC 1402, université de Poitiers, 86000 Poitiers, France
| | - France Artzner
- Ciane, Collectif interassociatif autour de la naissance, c/o Anne Evrard, 101, rue Pierre-Corneille, 69003 Lyon, France
| | - Arounie Tavenet
- Endofrance, Association de lutte contre l'endométriose, 3, rue de la Gare, 70190 Tresilley, France
| | - Camille Le Ray
- Maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, université Paris cité, FHU Prema, 75014 Paris, France
| | - Arnaud Fauconnier
- Service de gynécologie-obstétrique, centre hospitalier de Poissy Saint-Germain-en-Laye, 78300 Poissy, France
| |
Collapse
|
5
|
Shao M, Wang X, Zhou X. Case Report: Ovarian pregnancy, a rare but lethal condition: An analysis of 112 cases. Front Surg 2023; 10:1062228. [PMID: 36874462 PMCID: PMC9982079 DOI: 10.3389/fsurg.2023.1062228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/11/2023] [Indexed: 02/19/2023] Open
Abstract
Study Objective To explore how to improve the treatment, and prognosis of ovarian pregnancy (OP). Patients A total of 111 OP patients, one of the patients suffered from OP twice. Results In this study, 112 OP cases confirmed by postoperative pathology were retrospectively analyzed. Common risk factors for OP were previous abdominal surgery (39.29%) and intrauterine device use (18.75%). We modified the ultrasonic classification into four types: gestational sac type, hematoma type I, hematoma type II, and intraperitoneal hemorrhage type. Among these four types, the proportion of patients who underwent emergency surgery as initial treatment after admission was 68.75%, 10.00%, 92.00%, and 81.36%, respectively. The treatment for hematoma type I patients was often delayed. The rate of OP rupture was 86.61%. All methotrexate therapy for OP patients failed. All these 112 cases underwent surgery treatment finally. The surgical procedures were pregnancy ectomy and ovarian reconstruction by laparoscopy or laparotomy. No significant differences were observed in the operation time or intraoperative blood loss between laparoscopy and laparotomy. Laparoscopy showed less influence on patients regarding length of hospital stay and postoperative fever than laparotomy. Further, 49 patients who desired fertility were followed up over 3 years. Among them, 24 (48.98%) experienced spontaneous intrauterine pregnancy. Conclusion Among the four modified ultrasonic classifications, hematoma type I was associated with more delays in surgical time. Laparoscopic surgery was a better choice for OP treatment. The reproductive prognosis of OP patients was promising.
Collapse
Affiliation(s)
- Mengyuan Shao
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xinyi Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xin Zhou
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
6
|
Ultrasound Measured Depth of Pelvic Free Fluid Correlates Well with Blood Loss Volume in Patients with Ectopic Pregnancy. Emerg Med Int 2020; 2020:8874581. [PMID: 33376608 PMCID: PMC7746468 DOI: 10.1155/2020/8874581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/10/2020] [Accepted: 11/28/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose The ultrasonic finding of pelvic free fluid which suggests the possibility of internal haemorrhage helps the determination of the severity of patients. Methods We conducted a retrospective study investigating ultrasonic measurements and haemorrhage volumes in patients having an ectopic pregnancy in a single centre from January 2013 to November 2016. The logistic regression model was used to establish the prediction model for haemorrhage volumes. The diagnostic accuracy was evaluated by area under ROC curve (AUC) analysis. We employed 800 ml as the cut-off point of the haemorrhage and further set it to 1000 ml and 1200 ml in the sensitivity analysis. Results The mean pelvic free fluid depths measured by TVS and TAS were 4.45 ± 2.15 cm and 4.45 ± 2.56 cm in the haemorrhage ≥800 ml group, while they were 2.48 ± 1.51 cm and 2.55 ± 1.19 cm in <800 ml group. AUCs and the corresponding cut-off points were 0.741 (95% CI 0.677 to 0.804) and 0.118 when predicted by the standardised depths of TVS and TAS, 0.784 (95% CI 0.696–0.872) and 2.95 cm by the raw depths of TVS, and 0.748 (95% CI 0.665–0.831) and 3.35 cm by the raw depths of TAS. Conclusions The depth of pelvic free fluid measured by TVS and TAS can be used to predict blood loss volume in patients having an ectopic pregnancy. TVS may perform better than TAS.
Collapse
|
7
|
Varas C, Ravit M, Mimoun C, Panel P, Huchon C, Fauconnier A. Optimal Combination of Non-Invasive Tools for the Early Detection of Potentially Life-Threatening Emergencies in Gynecology. PLoS One 2016; 11:e0162301. [PMID: 27583697 PMCID: PMC5008751 DOI: 10.1371/journal.pone.0162301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/20/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives Potentially life-threatening gynecological emergencies (G-PLEs) are acute pelvic conditions that may spontaneously evolve into a life-threatening situation, or those for which there is a risk of sequelae or death in the absence of prompt diagnosis and treatment. The objective of this study was to identify the best combination of non-invasive diagnostic tools to ensure an accurate diagnosis and timely response when faced with G-PLEs for patients arriving with acute pelvic pain at the Gynecological Emergency Department (ED). Methods The data on non-invasive diagnostic tools were sourced from the records of patients presenting at the ED of two hospitals in the Parisian suburbs (France) with acute pelvic pain between September 2006 and April 2008. The medical history of the patients was obtained through a standardized questionnaire completed for a prospective observational study, and missing information was completed with data sourced from the medical forms. Diagnostic tool categories were predefined as a collection of signs or symptoms. We analyzed the association of each sign/symptom with G-PLEs using Pearson’s Chi-Square or Fischer’s exact tests. Symptoms and signs associated with G-PLEs (p-value < 0.20) were subjected to logistic regression to evaluate the diagnostic value of each of the predefined diagnostic tools and in various combinations. Results The data of 365 patients with acute pelvic pain were analyzed, of whom 103 were confirmed to have a PLE. We analyzed five diagnostic tools by logistic regression: Triage Process, History-Taking, Physical Examination, Ultrasonography, and Biological Exams. The combination of History-Taking and Ultrasonography had a C-index of 0.83, the highest for a model combining two tools. Conclusions The use of a standardized self-assessment questionnaire for history-taking and focal ultrasound examination were found to be the most successful tool combination for the diagnosis of gynecological emergencies in a Gynecological ED. Additional tools, such as physical examination, do not add substantial diagnostic value.
Collapse
Affiliation(s)
- Catalina Varas
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Marion Ravit
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Camille Mimoun
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Pierre Panel
- Department of Gynecology and Obstetrics, Mignot Hospital, Le Chesnay, France
| | - Cyrille Huchon
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Arnaud Fauconnier
- EA 7285 Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- * E-mail:
| |
Collapse
|
8
|
Analysis of ectopic pregnancies admitted to emergency department. Turk J Emerg Med 2016; 15:151-4. [PMID: 27239617 PMCID: PMC4882212 DOI: 10.1016/j.tjem.2016.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/02/2022] Open
Abstract
Objectives Ectopic pregnancy (EP) may cause significant morbidity and mortality. In this study, we aimed to evaluate the demographic characteristics, presence of risk factors and diagnostic parameters of the patient with EP and predicting parameters for ruptured EP. Methods Patients who presented to emergency department (ED) and diagnosed as EP within one year were included to the study. The demographic characteristics, β-human chorionic gonadotropin (β-HCG) levels, transvaginal ultrasonography (TVUSG) findings, treatment protocols, pathology reports and hemoglobin levels at the time of admission to ED were obtained from patient files and hospital automation system and statistical analysis was performed. Results Total 35 patients were included to the study. The mean age of the patients was 30 ± 5.6 years. Among the patients, 46% had a history of caesarean section (C-section). The complaints of the patients at presentation, their age, gestational week and the β-HCG levels were found to be inefficient in predicting ruptured EPs. TVUSG was found statistically significant in terms of demonstrating ruptures in EP. The ratio of salpingectomies was observed to be higher in the surgical treatment of ruptured EPs. Conclusions C-section was most frequently seen with EP. There is no absolute diagnostic parameter for predicting ruptured EPs and TVUSG may be a clue for diagnosis. The final diagnosis is made through surgery.
Collapse
|
9
|
Miyauchi A, Yamada M, Furuya M, Matsumura S, Murayama S, Yoshimura Y, Tanaka M. Peritoneal pregnancy with massive hemoperitoneum in early gestation: two case reports. Clin Case Rep 2015; 3:431-7. [PMID: 26185643 PMCID: PMC4498857 DOI: 10.1002/ccr3.266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 12/21/2014] [Accepted: 02/20/2015] [Indexed: 11/09/2022] Open
Abstract
Peritoneal pregnancy may cause severe abdominal bleeding without genital bleeding as early as the fifth week of gestation. Awareness that pregnancy can exist in unusual locations is imperative.
Collapse
Affiliation(s)
- Azumi Miyauchi
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Mitsutoshi Yamada
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masataka Furuya
- Department of Obstetrics and Gynecology, Eiju General Hospital 2-23-16 Higashiueno, Taito-ku, Tokyo, 110-0015, Japan
| | - Satoko Matsumura
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shinji Murayama
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yasunori Yoshimura
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| |
Collapse
|
10
|
Lesavre M, Curinier S, Capmas P, Rabischong B, Fernandez H. [Treatment of tubal ectopic pregnancy by methotrexate]. ACTA ACUST UNITED AC 2015; 44:212-9. [PMID: 25661494 DOI: 10.1016/j.jgyn.2014.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/02/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To make a literature analyse about methotrexate as a treatment of tubal ectopic pregnancy. MATERIALS AND METHODS We made a PubMed research and found articles, randomized control studies, systematic revues and meta-analyses of the Cochrane Database about ectopic pregnancies treated by methotrexate. We made a summary of these articles. RESULTS Methotrexate can be used as a treatment of tubal ectopic pregnancy with hCG<5000 UI/L and expectative is an option if hCG level is lower than 1500 UI/L. Medical treatment by methotrexate seems to be less effective than surgical salpingotomy but the rate of recurrence and the rate of intra-uterine pregnancy are similar regardless of the treatment chosen. Fertility seems to be the same after treatment by methotrexate. Economically, methotrexate is less expensive than the surgical management (laparoscopy). CONCLUSION Methotrexate can be used as a treatment of tubal ectopic pregnancies if every criterions of safety are gathered.
Collapse
Affiliation(s)
- M Lesavre
- Service de gynécologie-obstétrique, CHU Bicêtre, 78, avenue du général-Leclerc, 94276 Le Kremlin-Bicêtre, France.
| | - S Curinier
- Service de gynécologie-obstétrique, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont Ferrand, France
| | - P Capmas
- Service de gynécologie-obstétrique, CHU Bicêtre, 78, avenue du général-Leclerc, 94276 Le Kremlin-Bicêtre, France
| | - B Rabischong
- Service de gynécologie-obstétrique, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont Ferrand, France
| | - H Fernandez
- Service de gynécologie-obstétrique, CHU Bicêtre, 78, avenue du général-Leclerc, 94276 Le Kremlin-Bicêtre, France
| |
Collapse
|
11
|
Nathan HL, El Ayadi A, Hezelgrave NL, Seed P, Butrick E, Miller S, Briley A, Bewley S, Shennan AH. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG 2014; 122:268-75. [DOI: 10.1111/1471-0528.13206] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2014] [Indexed: 11/29/2022]
Affiliation(s)
- HL Nathan
- Women's Health Academic Centre; King's College London; London UK
| | - A El Ayadi
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - NL Hezelgrave
- Women's Health Academic Centre; King's College London; London UK
| | - P Seed
- Women's Health Academic Centre; King's College London; London UK
| | - E Butrick
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - S Miller
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - A Briley
- Women's Health Academic Centre; King's College London; London UK
| | - S Bewley
- Women's Health Academic Centre; King's College London; London UK
| | - AH Shennan
- Women's Health Academic Centre; King's College London; London UK
| |
Collapse
|
12
|
Frates MC, Doubilet PM, Peters HE, Benson CB. Adnexal sonographic findings in ectopic pregnancy and their correlation with tubal rupture and human chorionic gonadotropin levels. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:697-703. [PMID: 24658951 DOI: 10.7863/ultra.33.4.697] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To determine whether the distribution of transvaginal sonographic findings of ectopic pregnancy has changed since the studies done 20 years ago and to explore the correlation of tubal rupture with transvaginal sonographic findings and human chorionic gonadotropin (hCG) levels. METHODS Patients with ectopic pregnancy who underwent transvaginal sonography before treatment were included. Sonograms and medical records were retrospectively reviewed. The presence of a tubal ring, the presence of a yolk sac, embryonic cardiac activity, the degree of vascularity on color Doppler imaging, hCG levels, and results of surgery were recorded. RESULTS Our study included 231 ectopic pregnancies. A positive sonographic adnexal finding was present in 219 cases (94.8%): adnexal mass in 218 (94.4%) and a moderate-to-large amount of free fluid in 84 (36.4%). The adnexal masses were graded as follows: 1, nonspecific mass (125 cases [54.1% of total]); 2, tubal ring without a yolk sac or embryo (57 [24.7%]); 3, yolk sac but no embryonic heartbeat (19 [8.3%]); and 4, embryo with cardiac activity (17 [7.4%]). The mean hCG level increased as the grade ascended from 1 to 4. Thirty-six patients had tubal rupture at surgery within 24 hours of the sonogram. A moderate-to-large amount of free fluid was significantly associated with tubal rupture (P < .05) but had low sensitivity, specificity, and positive predictive value for rupture. Other sonographic findings and hCG levels were not significantly related to tubal rupture. CONCLUSIONS Transvaginal sonography showed an adnexal abnormality in nearly 95% of our patients with ectopic pregnancy, most commonly a nonspecific adnexal mass. Embryonic cardiac activity was seen in fewer than 10%. Neither sonographic findings nor hCG levels were useful predictors of tubal rupture.
Collapse
Affiliation(s)
- Mary C Frates
- Department of Radiology, Brigham and Women's Hospital Harvard Medical School, 75 Francis St, Boston, MA 02115 USA.
| | | | | | | |
Collapse
|
13
|
Abstract
PURPOSE Ectopic pregnancy (EP) presents a major health problem for women of child-bearing age. EP refers to the pregnancy occurring outside the uterine cavity that constitutes 1.2-1.4 % of all reported pregnancies. All identified risk factors are maternal: pelvic inflammatory disease, Chlamydia trachomatis infection, smoking, tubal surgery, induced conception cycle, and endometriosis. These developments have provided the atmosphere for trials using methotrexate as a non-surgical treatment for EP. The diagnosis measure of EP is serum human chorionic gonadotropin, urinary hCGRP/i-hCG, progesterone measurement, transvaginal ultrasound scan, computed tomography, vascular endothelial growth factor, CK, disintegrin and metalloprotease-12 and hysterosalpingography. The treatment option of EP involves surgical treatment by laparotomy or laparoscopy, medical treatment is usually systemic or through local route, or by expectant treatment. RESULTS It was concluded that review data reflect a decrease in surgical treatment and not an actual decline in EP occurrence so that further new avenues are needed to explore early detection of the EP.
Collapse
|
14
|
van Mello NM, Zietse CS, Mol F, Zwart JJ, van Roosmalen J, Bloemenkamp KW, Ankum WM, van der Veen F, Mol BWJ, Hajenius PJ. Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care. Fertil Steril 2012; 97:623-9. [DOI: 10.1016/j.fertnstert.2011.12.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 12/13/2011] [Accepted: 12/16/2011] [Indexed: 11/26/2022]
|
15
|
Huchon C, Panel P, Kayem G, Bassot A, Nguyen T, Falissard B, Fauconnier A. Is a standardized questionnaire useful for tubal rupture screening in patients with ectopic pregnancy? Acad Emerg Med 2012; 19:24-30. [PMID: 22221975 DOI: 10.1111/j.1553-2712.2011.01238.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Physical examination, ultrasonography, and laboratory tests fail to reliably establish the preoperative diagnosis of tubal rupture in patients with ectopic pregnancy (EP), leading to a high rate of diagnostic laparoscopy. The aim of this study was to construct and to evaluate a clinical prediction rule for tubal rupture screening based on a self-assessment questionnaire, among patients with EP. METHODS A standardized questionnaire was constructed via semistructured interviews of patients with acute pelvic pain. Features associated with tubal rupture were then identified in 141 prospectively included patients with tubal pregnancy, including 30 with tubal rupture, in five hospitals. Multiple logistic regression was used to select the best combination of independent features for predicting tubal rupture. Cross-validation was with the jackknife method. The main outcome measure was diagnostic accuracy of the questionnaire for ruling out tubal rupture. RESULTS Eighty-nine items characterizing acute pelvic pain were identified. Among them, four contributed independently to the diagnosis of tubal rupture: vomiting during pain, diffuse abdominal pain, acute pain for longer than 30 minutes, and flashing pain. The presence of one or more of these features had 93% sensitivity (95% confidence interval [CI] = 84% to 100%) and 44% specificity (95% CI = 35% to 53%) for tubal rupture, with a negative likelihood ratio for ruling out tubal rupture of 0.16. CONCLUSIONS These results suggest that a standardized questionnaire may contribute to ruling out tubal rupture in patients with EP.
Collapse
Affiliation(s)
- Cyrille Huchon
- Service de Gynécologie et Obstétrique, CHI Poissy Saint-Germain en Laye, Poissy, France.
| | | | | | | | | | | | | |
Collapse
|
16
|
Popowski T, Huchon C, Toret-Labeeuw F, Chantry AA, Aegerter P, Fauconnier A. Hemoperitoneum assessment in ectopic pregnancy. Int J Gynaecol Obstet 2011; 116:97-100. [DOI: 10.1016/j.ijgo.2011.09.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/07/2011] [Accepted: 10/26/2011] [Indexed: 10/15/2022]
|
17
|
Baxi A, Kaushal M, Karmalkar H, Sahu P, Kadhi P, Daval B. Successful expectant management of tubal heterotopic pregnancy. J Hum Reprod Sci 2011; 3:108-10. [PMID: 21209757 PMCID: PMC2970786 DOI: 10.4103/0974-1208.69333] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 05/22/2010] [Accepted: 06/14/2010] [Indexed: 11/16/2022] Open
Abstract
Expectant management for tubal heterotopic pregnancy could be considered as a successful option in a symptom-free patient where the ectopic embryo has a limited craniocaudal length with no cardiac activity. We report the obstetric outcome after expectant management for a right tubal heterotopic pregnancy. Heterotopic pregnancy was first recognized at 6 weeks gestation in a 32-year-old salpingectomized woman with an 8-year history of subfertility who conceived after in utero transfer of three embryos obtained by in vitro fertilization. Expectant management and close ultrasonographic and clinical monitoring were done. The intrauterine pregnancy proceeded unremarkably. A cesarean section was performed for breech presentation, and it allowed the delivery of a healthy 2260-g male infant. The examination of the adnexa showed a pre-rupture of the right fallopian tube.
Collapse
Affiliation(s)
- Asha Baxi
- Disha Fertility and Surgical Center, Indore, (M. P.), India
| | | | | | | | | | | |
Collapse
|
18
|
Abstract
Ectopic pregnancy (EP) remains the number one cause of first trimester maternal death. Traditionally, laparoscopy has been the gold standard for diagnosis of EP. The advent of high-resolution transvaginal scan (TVS) means more clinically stable women with EPs are diagnosed earlier, well before surgery becomes necessary in many cases. Early diagnosis by TVS is therefore potentially life saving and can reduce surgical morbidity by allowing elective surgery or even non-surgical conservative treatment options. Combining transabdominal and transvaginal scanning confers no benefit over transvaginal scanning alone. Reports that reads "…empty uterus, ectopic pregnancy cannot be excluded" should be a thing of the past. Diagnosis of EP should be based upon the positive identification of an adnexal mass using TVS rather than the absence of an intra-uterine gestational sac. A systematic approach to scanning the early pregnancy pelvis will diagnose the vast majority of EPs at the initial scan. Ultrasound, and in particular TVS, is fast becoming the new gold standard for diagnosis of all types of EP. In modern management, laparoscopy should be seen as the operative tool of choice while TVS the diagnostic tool of choice.
Collapse
Affiliation(s)
- 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
| | - 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
| |
Collapse
|
19
|
Cabar FR, Pereira PP, Schultz R, Francisco RP, Zugaib M. Vascular endothelial growth factor and β-human chorionic gonadotropin are associated with trophoblastic invasion into the tubal wall in ectopic pregnancy. Fertil Steril 2010; 94:1595-600. [DOI: 10.1016/j.fertnstert.2009.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 10/15/2009] [Accepted: 10/17/2009] [Indexed: 11/26/2022]
|
20
|
|
21
|
Bignardi T, Condous G. Does tubal ectopic pregnancy with hemoperitoneum always require surgery? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:711-715. [PMID: 19444867 DOI: 10.1002/uog.6384] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Hemoperitoneum is accepted as an indication for surgery in women with tubal ectopic pregnancy. The aim of this pilot study was to evaluate the feasibility of managing such women non-surgically. METHODS This was a prospective observational study. Women with tubal ectopic pregnancy and hemoperitoneum detected on transvaginal sonography (TVS) were managed as inpatients either expectantly or with methotrexate (MTX). Inclusion criteria for conservative management were: compliance, clinical stability, absence of acute abdomen, stable hemoglobin level on two measurements (0 and 12-24 h apart), serum human chorionic gonadotropin (hCG) < 5000 IU/L, absence of fetal cardiac activity on TVS and absence of significant hemoperitoneum, defined as blood above the level of the uterine fundus and/or in Morison's pouch (hepatorenal space). Subsequent management was based upon the hCG ratio at 48 h. All the women were managed as inpatients until the abdominal pain settled and the serum hCG levels were falling. RESULTS Forty-one women with tubal ectopic pregnancy presented between November 2006 and March 2008. Eight women (20%) fulfilled the entry criteria. The median gestational age at diagnosis was 49 (interquartile range, 38-52.5) days. All women presented with lower abdominal pain/right iliac fossa or left iliac fossa pain. Hemoglobin levels ranged from 11.2 to 14.2 g/dL at presentation and from 12.0 to 14.8 g/dL after 12-24 h. 6/8 (75%) women were managed expectantly and 2/8 (25%) received MTX. All women had resolution of their ectopic pregnancy within 3 weeks with no complications. CONCLUSIONS This pilot study suggests that the finding of hemoperitoneum on ultrasound examination may not be an absolute contraindication to conservative management of tubal ectopic pregnancy.
Collapse
Affiliation(s)
- T Bignardi
- Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith, Sydney, Australia.
| | | |
Collapse
|
22
|
Salomon L, Nassar M, Bernard J, Ville Y, Fauconnier A. A score-based method to improve the quality of emergency gynaecological ultrasound examination. Eur J Obstet Gynecol Reprod Biol 2009; 143:116-20. [DOI: 10.1016/j.ejogrb.2008.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 09/30/2008] [Accepted: 12/22/2008] [Indexed: 10/21/2022]
|
23
|
|
24
|
Birkhahn RH, Gaeta TJ, Bei R, Bove JJ. Shock Index in the First Trimester of Pregnancy and Its Relationship to Ruptured Ectopic Pregnancy. Acad Emerg Med 2008. [DOI: 10.1197/aemj.9.2.115] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Robert H. Birkhahn
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY
| | - Theodore J. Gaeta
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY
| | - Robert Bei
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY
| | - Joseph J. Bove
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY
| |
Collapse
|
25
|
Fauconnier A, Mabrouk A, Salomon LJ, Bernard JP, Ville Y. Ultrasound assessment of haemoperitoneum in ectopic pregnancy: derivation of a prediction model. World J Emerg Surg 2007; 2:23. [PMID: 17825105 PMCID: PMC2040136 DOI: 10.1186/1749-7922-2-23] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 09/07/2007] [Indexed: 11/24/2022] Open
Abstract
Background To derive an ultrasound-based prediction model for the quantification of haemoperitoneum in ectopic pregnancy (EP). Methods Retrospective study of 89 patients operated upon EP between January 1999 and March 2003 in a French Gynaecology and Obstetrics department in a university hospital. Transvaginal sonograms, clinical and biological variables from patients with haemoperitoneum ≥ 300 ml at surgery were compared with those from patients with haemoperitoneum < 300 ml or no haemoperitoneum. Sensitivity, specificity, positive and negative likelihood ratios were calculated for each parameter after appropriate dichotomization. Multiple logistic regression analysis was used to select the best combination at predicting haemoperitoneum ≥ 300 ml. Results Three parameters predicted haemoperitoneum ≥ 300 ml independently: moderate to severe spontaneous pelvic pain, fluid above the uterine fundus or around the ovary at transvaginal ultrasound, and serum haemoglobin concentration < 10 g/dL. A woman with none of these three criteria would have a probability of 5.3% for haemoperitoneum ≥ 300 ml. When two or more criterias were present, the probability for haemoperitoneum ≥ 300 ml reached 92.6%. Conclusion The proposed model accurately predicted significant haemoperitoneum in patients diagnosed to have EP.
Collapse
Affiliation(s)
- Arnaud Fauconnier
- Department of Gynaecology, Obstetrics and Reproductive medicine, CHI Poissy-St-Germain, Saint-Germain-En-Laye, France
| | - Ali Mabrouk
- Department of Gynaecology, Obstetrics and Reproductive medicine, CHI Poissy-St-Germain, Saint-Germain-En-Laye, France
| | - Laurent J Salomon
- Department of Gynaecology, Obstetrics and Reproductive medicine, CHI Poissy-St-Germain, Saint-Germain-En-Laye, France
| | - Jean-Pierre Bernard
- Department of Gynaecology, Obstetrics and Reproductive medicine, CHI Poissy-St-Germain, Saint-Germain-En-Laye, France
| | - Yves Ville
- Department of Gynaecology, Obstetrics and Reproductive medicine, CHI Poissy-St-Germain, Saint-Germain-En-Laye, France
| |
Collapse
|
26
|
Guvendag Guven ES, Dilbaz S, Dilbaz B, Guven S, Sahin Ozdemir D, Haberal A. Serum biochemistry correlates with the size of tubal ectopic pregnancy on sonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 28:826-30. [PMID: 17031874 DOI: 10.1002/uog.3822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To investigate whether there is a correlation between serum biochemistry (human chorionic gonadotropin (hCG), CA 125, progesterone and estradiol) and the common sonographic findings (blob sign, bagel sign or extrauterine gestational sac with cardiac activity) or size of a tubal ectopic pregnancy, and whether there is a difference in serum biochemistry between women with a tubal ectopic pregnancy who are hemodynamically unstable (tachycardia, hypotension, falling hemoglobin levels and/or acute severe abdominal pain) and those who are hemodynamically stable. METHODS This was a prospective cohort study of 106 women with a tubal ectopic pregnancy. We noted transvaginal ultrasound examination findings including adnexal mass size, and the serum levels of hCG, CA 125, progesterone and estradiol. The data were analyzed retrospectively. RESULTS The mean maternal and gestational ages were 30.7+/-5.7 years and 44+/-4.2 days, respectively. There was no correlation between serum markers and common sonographic findings. However, in the presence of the bagel sign on ultrasound, hemodynamic stability was more common (P=0.03). The mean serum hCG concentrations in tubal ectopic pregnancies<20 mm, 20-40 mm and >40 mm in size were 2225.3+/-3166.9, 4124.8+/-6121.4, and 11 011.8+/-12 670.1 IU/mL, respectively (P<0.001). Serum hCG, CA 125 and estradiol values were well correlated with adnexal mass size; for CA 125 this correlation was linear. There was no difference in serum biochemistry between hemodynamically stable and hemodynamically unstable women. CONCLUSION Common sonographic findings of tubal ectopic pregnancy do not correlate with serum biochemistry. High levels of CA 125, hCG or estradiol may suggest a larger adnexal mass in women with uncomplicated tubal pregnancies. Hemodynamically stable and hemodynamically unstable women do not differ in their serum biochemistry.
Collapse
Affiliation(s)
- E S Guvendag Guven
- Department of Obstetrics and Gynaecology, Ministry of Health, Etlik Women's Health and Maternity Teaching and Research Hospital, Ankara, and Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey.
| | | | | | | | | | | |
Collapse
|
27
|
Berlingieri P, Bogdanskiene G, Grudzinskas JG. Rupture of tubal pregnancy in the Vilnius population. Eur J Obstet Gynecol Reprod Biol 2006; 131:85-88. [PMID: 16621223 DOI: 10.1016/j.ejogrb.2006.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Revised: 01/19/2006] [Accepted: 03/12/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the determinants of tubal rupture in women who suffered from ectopic pregnancy in relation to their demographic profile and medical history. STUDY DESIGN This retrospective observational clinical study was conducted in five general hospitals in Vilnius, Lithuania. The population was composed of 879 women with surgically proven ectopic pregnancy. Tubal rupture was diagnosed at the time of surgery. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for tubal rupture. RESULTS The occurrence of tubal rupture was 29.5% (259/879). It was encountered significantly more often in women with age of > or =35 years (odds ratio 1.9 [1.3-2.8]). Patients whose EP was located in the isthmus were at higher risk of having tubal rupture (odds ratio 3.2 [2.2-4.5]) while known risk factors for EP were not associated with an elevated risk. CONCLUSIONS Our data suggest that age of > or =35 years and implantation in the straightest segment of the tube could be associated with increased rate of tubal rupture. Of particular interest is the overall tubal rupture prevalence (29.5%) observed since these women were managed in an environment where transvaginal ultrasound equipment and quantitative assessment of beta-human chorionic gonadotrophin were not routinely available.
Collapse
Affiliation(s)
- Pasquale Berlingieri
- Department of Obstetrics and Gynaecology, St. Bartholomew's and The Royal London School of Medicine and Dentistry, London, United Kingdom.
| | | | - Jurgis G Grudzinskas
- Department of Obstetrics and Gynaecology, St. Bartholomew's and The Royal London School of Medicine and Dentistry, London, United Kingdom; The London Bridge Fertility, Gynaecology and Genetics Centre, London, United Kingdom
| |
Collapse
|
28
|
Abstract
Ectopic pregnancy is a life- and fertility-threatening condition that is commonly seen in Canadian emergency departments. Increases in the availability and use of hormonal markers, coupled with advances in formal and emergency ultrasonography have changed the diagnostic approach to the patient in the emergency department with first-trimester bleeding or pain. Ultrasonography should be the initial investigation for symptomatic women in their first trimester; when the results are indeterminate, the serum beta human chorionic gonadotropin (beta-hCG) concentration should be measured. Serial measurement of beta-hCG and progesterone concentrations may be useful when the diagnosis remains unclear. Advances in surgical and medical therapy for ectopic pregnancy have allowed the proliferation of minimally invasive or noninvasive treatment. Guidelines for laparoscopy and for methotrexate therapy are provided.
Collapse
Affiliation(s)
- Heather Murray
- Department of Emergency Medicine, Queen's University, Kingston, Ont.
| | | | | | | |
Collapse
|
29
|
Kumtepe Y, Kadanali S. Medical treatment of ruptured with hemodynamically stable and unruptured ectopic pregnancy patients. Eur J Obstet Gynecol Reprod Biol 2004; 116:221-5. [PMID: 15358469 DOI: 10.1016/j.ejogrb.2004.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2003] [Accepted: 03/10/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the success rate of methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable and unruptured ectopic pregnancy patients. STUDY DESIGN This prospective clinical study was carried out on 161 patients with suspected tubal ectopic pregnancy. Fourty-six patients have been accepted as ruptured ectopic pregnancy with hemodynamically stable and 115 patients have been accepted as unruptured ectopic pregnancy. All patients diagnosed with ectopic pregnancy were treated by single dose (50 mg/m2) methotrexate if they have stable hemodynamia and fulfill the criteria of methotrexate treatment. Weekly beta-hCG level was measured and if this level was under 10 IU/L, the treatment has been accepted as successful. Mann-Whitney and Fisher's exact tests were used (SPSS, 10.0) for statistical analysis. RESULTS The success rates of methotrexate treatments in ruptured ectopic pregnancy patients with hemodynamically stable and in patients with unruptured ectopic pregnancy were observed as 62% and 81%, respectively (P < 0.001). The treatment was successfully completed in all expectant management patients. CONCLUSION Although methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable patients is not as successful as in unruptured ectopic pregnancy group, 62% success rate in this group may promise a treatment choice before surgery application.
Collapse
Affiliation(s)
- Yakup Kumtepe
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ataturk University, 25200 Erzurum, Turkey.
| | | |
Collapse
|
30
|
Birkhahn RH, Gaeta TJ, Van Deusen SK, Tloczkowski J. The ability of traditional vital signs and shock index to identify ruptured ectopic pregnancy. Am J Obstet Gynecol 2003; 189:1293-6. [PMID: 14634556 DOI: 10.1067/s0002-9378(03)00663-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study evaluated the correlation between vital signs and hemoperitoneum and the association between abnormal vital signs and tubal rupture. STUDY DESIGN With the use of a retrospective case-control design, the initial heart rate, systolic blood pressure, and heart rate/systolic blood pressure were correlated with respect to degree of hemoperitoneum; predictive values were calculated. RESULTS Fifty-two patients were studied (25 ruptured pregnancies and 27 unruptured ectopic pregnancies). Correlation coefficients were heart rate (r=0.50; 95% CI, 0.26-0.68), systolic blood pressure (r=-0.34; 95% CI, -0.56 to -0.08), and heart rate/systolic blood pressure (r=0.69; 95% CI, 0.51-0.81). The sensitivity for heart rate, systolic blood pressure, and heart rate/systolic blood pressure was 28%, 36%, and 72% respectively; the specificity was 96%, 96%, and 67%, respectively. CONCLUSION Normal vital signs alone are poor predictors of ruptured ectopic pregnancy; the heart rate/systolic blood pressure correlates best with the quantity of intraperitoneal hemorrhage.
Collapse
Affiliation(s)
- Robert H Birkhahn
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY 11215, USA.
| | | | | | | |
Collapse
|
31
|
|
32
|
Mol BWJ, van der Veen F, Bossuyt PMM. Symptom-free women at increased risk of ectopic pregnancy: should we screen? Acta Obstet Gynecol Scand 2002; 81:661-72. [PMID: 12190842 DOI: 10.1034/j.1600-0412.2002.810713.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transvaginal sonography, serum human chorionic gonadotrophin (hCG) measurement, and serum progesterone measurement provide the possibility to screen symptom-free women at increased risk of ectopic pregnancy. The objective of the present study was to evaluate the cost-effectiveness of screening for ectopic pregnancy, by addressing the expected benefits and costs of screening for ectopic pregnancy. METHODS Screening programs incorporating transvaginal sonography, serum hCG measurement, and serum progesterone measurement were compared with a 'watchful waiting' strategy. Data were extracted from the literature. The strategies were compared on the expected number of prevented tubal ruptures, the expected number of false-positive diagnoses, and expected costs. RESULTS The cost-effectiveness of screening appeared to be strongly dependent on the prevalence of ectopic pregnancy. At a prevalence of ectopic pregnancy of 6%, a screening program with transvaginal sonography and serum hCG measurement would reduce the number of patients with ruptured ectopic pregnancy from 2.1 to 0.61 per 100 screened women. Screening was expected to cost approximately Euro 933 per prevented tubal rupture, whereas the number of expected false-positive diagnoses was 0.64 per prevented tubal rupture. CONCLUSION We conclude that screening for ectopic pregnancy reduces the number of patients with tubal rupture, but only at the expense of a large false-positive rate. Although sonography in symptom-free women at risk of ectopic pregnancy might be justified for psychological reasons, the medical and economic benefits of such a policy seem to be limited.
Collapse
Affiliation(s)
- Ben W J Mol
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | | | | |
Collapse
|
33
|
Sowter MC, Farquhar CM, Petrie KJ, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. BJOG 2001; 108:192-203. [PMID: 11236120 DOI: 10.1111/j.1471-0528.2001.00038.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare single dose systemic methotrexate (50 mg/m2) with laparoscopic surgery for the treatment of unruptured tubal pregnancy. DESIGN An open, pragmatic, prospective randomised trial. SETTING Departments of obstetrics and gynaecology at three hospitals in Auckland, New Zealand. PARTICIPANTS Clinically stable women with an unruptured tubal pregnancy diagnosed by transvaginal ultrasound and quantitative serum beta-hCG measurement. Inclusion criteria included a serum beta-hCG concentration < 5,000 IU/L, and a tubal pregnancy of < 3.5 cm diameter. MAIN OUTCOME MEASURES Treatment success, physical and psychological functioning, side effects, and subsequent ipsilateral tubal patency. RESULTS Two hundred and eighteen women with ectopic pregnancies were seen at the three hospitals. 79 women (36% eligibility rate) were eligible for trial entry and 62 women (78% recruitment rate) were recruited. Twenty-six of the 28 women (93%) randomised to laparoscopic surgery required no further treatment, compared with 22 of the 34 women (65%) randomised to methotrexate (95% CI of difference in success rate 10 - 47%; P < 0.01). Two women (7%) in the laparoscopic surgery group had persistent trophoblast. Nine women (26%) in the methotrexate group required more than one dose of methotrexate and five women (15%) underwent laparoscopy during follow up. In the laparoscopy group three women (11%) had negative laparoscopies and two women (7%) had were found to have a ruptured fallopian tube at the time of surgery. Women treated with methotrexate had significantly better objective physical functioning scores but there were no differences in any other psychological outcomes. Women treated with methotrexate experienced greater and more prolonged vaginal bleeding. The likelihood of methotrexate treatment failure was greater at higher serum beta-hCG concentrations. Ipsilateral tubal patency rates were similar in each group. CONCLUSION This trial shows that in the treatment of tubal pregnancy single dose systemic methotrexate is a less effective treatment than laparoscopic salpingotomy. It is well tolerated, but should only be offered as an alternative to surgery to women who have mild symptoms and present at low serum beta-hCG concentrations. In our population this likely to be no more than a quarter of women presenting with a tubal pregnancy.
Collapse
Affiliation(s)
- M C Sowter
- University Department of Obstetrics and Gynaecology, National Women's Hospital, Auckland, New Zealand
| | | | | | | |
Collapse
|
34
|
Sowter MC, Farquhar CM, Petrie KJ, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0306-5456(00)00038-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
35
|
Mol BW, van Der Veen F, Bossuyt PM. Implementation of probabilistic decision rules improves the predictive values of algorithms in the diagnostic management of ectopic pregnancy. Hum Reprod 1999; 14:2855-62. [PMID: 10548636 DOI: 10.1093/humrep/14.11.2855] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Current algorithms for the diagnosis of ectopic pregnancy do not take into account the heterogeneity in patient profiles. Such heterogeneity can lead to differences in the pre-test probability of ectopic pregnancy. In patients with clinical symptoms, for example, the probability of presence of an ectopic pregnancy is higher than in symptom-free patients. Any additional tests should then be interpreted differently, depending on the pre-test probability. We present a diagnostic algorithm that uses probabilistic decision rules for the evaluation of women with suspected ectopic pregnancy with flexible cut-off levels for test positivity We compare it with a general algorithm that uses fixed cut-off levels. Fictitious cohorts, varying in prevalence of ectopic pregnancy were put together, using data obtained from a cohort of >800 women with suspected ectopic pregnancy. In the inflexible algorithm, ectopic pregnancy was diagnosed whenever it could be visualized at transvaginal sonography, or where serum human chorionic gonadotrophin (HCG) exceeded a rigid cut-off level; ectopic pregnancy was rejected if an intrauterine pregnancy was seen or when serum HCG decreased. In the flexible algorithm, a post-test probability was obtained after each test, using pre-test probabilities and test-based likelihood ratios. Ectopic pregnancy was diagnosed whenever the post-test probability for ectopic pregnancy exceeded 95%, whereas this diagnosis was rejected if the calculated post-test probability fell below 1%. For both algorithms, sensitivity and specificity as well as predictive values were calculated. At each prevalence, the inflexible algorithm was associated with a sensitivity of 93% and a specificity of 97%. In contrast, the sensitivity and specificity of the flexible, individualized algorithm depended on the prevalence of ectopic pregnancy. Consequently, predictive values varied strongly when the inflexible algorithm was used, whereas they were much more stable after using the flexible algorithm. For five possible valuations of false positive and false negative diagnoses, the flexible algorithm reduced the expected disutility, compared with the inflexible algorithm. It is concluded that clinicians should incorporate probabilistic decision rules in algorithms used for the diagnosis of ectopic pregnancy.
Collapse
Affiliation(s)
- B W Mol
- Department of Clinical Epidemiology and Biostatistics and Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, the Netherlands
| | | | | |
Collapse
|