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Jeffers K, Koyfman A, Long B. Updates in emergency medicine: Ectopic pregnancy. Am J Emerg Med 2024; 85:90-97. [PMID: 39244808 DOI: 10.1016/j.ajem.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/24/2024] [Accepted: 09/01/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.
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Affiliation(s)
- Kristine Jeffers
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Marchand GJ, Masoud AT, Coriell C, Ulibarri H, Parise J, Arroyo A, Goetz S, Moir C, Moberly A, Govindan M. Treatment of Cesarean Scar Ectopic Pregnancy in China with Uterine Artery Embolization-A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:7393. [PMID: 36556010 PMCID: PMC9783593 DOI: 10.3390/jcm11247393] [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: 10/22/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Cesarean scar ectopic pregnancy (CSP) is a rare form of ectopic pregnancy, and treatment of CSP with uterine artery embolization (UAE) is a novel approach. With increasing numbers of cesarean sections being performed annually, the incidence of this condition is likely to increase. The authors became aware of an unusually high number of published studies originating in mainland China regarding this unusual treatment and sought to perform a meta-analysis to provide comprehensive evidence on this novel practice. METHODS We performed a thorough search and included all forms of quality studies on this topic that reported UAE as a part of first-line management of CSP. We included only studies originating in China. Ultimately, 37 studies were included for qualitative and quantitative synthesis of evidence. After screening retrieved records and extracting data from eligible studies, we pooled continuous data as a mean estimate and 95% confidence interval (CI), and dichotomous data as proportion and 95% CI. RESULTS CSP patients treated with protocols including UAE had a mean time of 30 days for serum β-hCG normalization, 95% CI [26.816, 33.881]. They had a mean estimated intraprocedural blood loss of 4.19 ± 3.76 mL, a mean hospital stay of nine days, 95%CI [7.914, 9.876], and a success rate of 93.4%, 95%CI [0.918, 0.951]. The severe complication rate was 1.2%, 95%CI [0.008, 0.017]. CONCLUSION UAE, in combination with other procedures is being used effectively for the treatment of CSP in China. Protocols including UAE have a success rate of approximately 93.4%, and a severe complication rate of approximately 1.2%. This data's utility is limited by vast differences in the studied protocols and questionable feasibility outside of China.
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Affiliation(s)
- Greg J. Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Ahmed Taher Masoud
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
- Faculty of Medicine, Fayoum University, Fayoum 63514, Egypt
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Sydnee Goetz
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Carmen Moir
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Atley Moberly
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Malini Govindan
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
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Salari N, Kazeminia M, Shohaimi S, Nankali AAD, Mohammadi M. Evaluation of treatment of previous cesarean scar pregnancy with methotrexate: a systematic review and meta-analysis. Reprod Biol Endocrinol 2020; 18:108. [PMID: 33168010 PMCID: PMC7650162 DOI: 10.1186/s12958-020-00666-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Previous caesarean scar pregnancy is one type of ectopic pregnancy in myometrium and fibrous tissue of previous caesarean scar. One of the therapeutic methods of this type of ectopic pregnancy is treatment with methotrexate. Given various findings on the treatment of caesarean scar pregnancy with methotrexate and lack of global report in this regard, we aimed to achieve a global report on the treatment of CSP with methotrexate through related literature review and analysis of the results of the studies, to enable more precise planning to reduce complications of CSP. METHOD This review study extracted information through searching national and international databases of SID،, Embase, ScienceDirect, ، Scopus, ، PubMed, Web of Science (ISI) between 2003 and January 2020. To perform the meta-analysis, random-effects model and heterogeneity of the studies with I2 index were investigated. Data were sanalysed using Comprehensive Meta-Analysis version 2. RESULTS In total, 26 articles with a sample size of 600 individuals were enrolled in the meta-analysis. According to the results of the study, the mean level of β-hCG was 28,744.98 ± 4425.1 mIU/ml before the intervention and was 23,836.78 ± 4533.1 mIU/ml after the intervention. The mean intraoperative blood loss (ml) was 4.8 ± 3.76 ml, mean hospital stay (days) was 11.7 ± 1.2 days, mean time for serum-hCG normalization (days) was 41.6 ± 3.2 days, success was 90.7% (95% CI: 86.7-93.5%), and complication was 9% (95% CI: 6.3-12.8%). CONCLUSION The results of the current study show methotrexate significantly reduces β-hCG levels and can be effective in treating caesarean scar pregnancy and its complications.
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Affiliation(s)
- Nader Salari
- grid.412112.50000 0001 2012 5829Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
- grid.412112.50000 0001 2012 5829Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Kazeminia
- grid.412112.50000 0001 2012 5829Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- grid.11142.370000 0001 2231 800XDepartment of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor Malaysia
| | - Anis al-Dawlah Nankali
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- grid.412112.50000 0001 2012 5829Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Bridi A, Perecin F, da Silveira JC. Extracellular Vesicles Mediated Early Embryo-Maternal Interactions. Int J Mol Sci 2020; 21:E1163. [PMID: 32050564 PMCID: PMC7037557 DOI: 10.3390/ijms21031163] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/23/2022] Open
Abstract
Embryo-maternal crosstalk is an important event that involves many biological processes, which must occur perfectly for pregnancy success. This complex communication starts from the zygote stage within the oviduct and continues in the uterus up to the end of pregnancy. Small extracellular vesicles (EVs) are part of this communication and carry bioactive molecules such as proteins, lipids, mRNA, and miRNA. Small EVs are present in the oviductal and uterine fluid and have important functions during fertilization and early embryonic development. Embryonic cells are able to uptake oviductal and endometrium-derived small EVs. Conversely, embryo-derived EVs might modulate oviductal and uterine function. In this review, our aim is to demonstrate the role of extracellular vesicles modulating embryo-maternal interactions during early pregnancy.
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A Retrospective Review of Patients Hospitalized in the Postoperative Intensive Care Unit due to Ectopic Pregnancy Rupture. ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2020. [DOI: 10.21673/anadoluklin.591224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Early in pregnancy women frequently experience nausea, vomiting, and vaginal bleeding. Nausea and vomiting can be mild, managed by dietary modifications and medications, or severe, requiring intravenous fluids and medications. Care should be used when selecting medications for nausea to avoid additional side effects or potential harm to the developing fetus. When evaluating vaginal bleeding in early pregnancy, ectopic pregnancy must be ruled out. If an intrauterine pregnancy is seen, threatened miscarriage should be considered and the patient appropriately counseled. If neither intrauterine pregnancy nor ectopic pregnancy can be established, a management algorithm for pregnancy of unknown location is presented.
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Affiliation(s)
- Elizabeth Pontius
- Department of Emergency Medicine, Georgetown University School of Medicine, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, 110 Irving Street, Northwest, NA 1177, Washington, DC 20010, USA
| | - Julie T Vieth
- Department of Emergency Medicine, Canton-Potsdam Hospital, 50 Leroy Street, Potsdam, NY 13676, USA.
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Zhang Y, Chen J, Lu W, Li B, Du G, Wan X. Clinical characteristics of persistent ectopic pregnancy after salpingostomy and influence on ongoing pregnancy. J Obstet Gynaecol Res 2017; 43:564-570. [PMID: 28127836 PMCID: PMC5347973 DOI: 10.1111/jog.13251] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/17/2016] [Accepted: 11/08/2016] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study was to assay the clinical characteristics of persistent ectopic pregnancy (PEP) and its influence on ongoing pregnancy. METHODS We retrospectively reviewed 2498 patients who received salpingostomies as primary management for ectopic pregnancies from January 2004 to December 2009, using medical records and telephone inquiries. Clinical characteristics of the 52 patients (2.08%) who were diagnosed with PEP after salpingostomy were compared with those who received satisfactory treatment. The odds ratios and 95% confidential intervals were calculated for each variable by univariate and (for significantly different factors) multivariate analysis. RESULTS Preoperatively, patients with PEP after salpingostomy significantly differed from the non-PEP patients in gestational age, mass size and pelvic adhesiolysis. Serum β-human chorionic gonadotropin levels in PEP patients were monitored after surgery, which had declined by 28.31% on postoperative day (POD) 4, 40.22% on POD 7, 51.46% on POD 10 and 53.43% on POD 21. Repeat ectopic pregnancy (REP) tended to occur more frequently in PEP patients (PEP: 5 cases, 10.20%; non-PEP: 4 cases, 2.80%; P = 0.034). Multivariate analysis showed that pelvic adhesions and PEP were the strongest independent predictors of REP. CONCLUSION Gestational age, mass size and pelvic adhesions were significantly correlated with PEP. PEP was an independent prognostic factor for REP. However, a multicenter study is needed to support and extend our findings.
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Affiliation(s)
- Yongli Zhang
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinhong Chen
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen Lu
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bilan Li
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guiqiang Du
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoping Wan
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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Saadati N, Najafian M, Masihi S, Safiary S, Abedi P. Comparison of Two Different Protocols of Methotrexate Therapy in Medical Management of Ectopic Pregnancy. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e20147. [PMID: 26756008 PMCID: PMC4706730 DOI: 10.5812/ircmj.20147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 07/15/2014] [Accepted: 08/13/2014] [Indexed: 11/30/2022]
Abstract
Background: Ectopic pregnancy (EP) is one of the most dangerous complications of pregnancy and without prompt diagnosis and treatment, it could become a major cause of maternal morbidity and mortality. Objectives: In this randomized controlled study, we compared single and double dose of methotrexate (MTX) therapy in the treatment of ectopic pregnancy. Patients and Methods: This study was performed on 76 patients who were admitted to Obstetrics Ward with primary diagnosis of ectopic pregnancy based on their medical history, physical examination, beta subunit (β-HCG) level, and transvaginal ultrasonography. Using random block allocation, the patients were classified in two groups of single dose and double dose administration of MTX. In single dose group, 50 mg/m2 of MTX was given at day 0 and in double dose group, the patients received two doses of MTX at day 0 and 4. The level of β-HCG was measured at day 0, 4, 7 in both groups. The successful treatment was defined as 15% reduction in β-HCG level between day 4 and 7. The two groups were compared with each other with regard to their need for operation, or extra dose of MTX; duration of hospitalization; and MTX complications. Results: Results showed that the rate of success in double dose method was more than single dose one (79% versus 69%) but the difference was not significant (P = 0.29). Although the need for operation and extra dose of MTX were lower in the double dose group (15.8% vs. 18.8% and 5.26% vs. 13.2%, respectively), these differences were not significant too. Duration of hospitalization was significantly lower in double dose compared to the single dose (11.55 d vs. 14.76 d, P < 0.001). Conclusions: Single dose therapy of MTX has sufficient power and efficacy in the treatment of ectopic pregnancy, however in patients with higher serum level of β-HCG, the successful treatment increases by using double dose method. Using double dose also could decrease the necessity of operation, re-administration of MTX, and duration of hospitalization.
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Affiliation(s)
- Najmieh Saadati
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Mahin Najafian
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
- Corresponding Author: Mahin Najafian, Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran. Tel: +98-9161188801, Fax: +98-6113738333, E-mail:
| | - Sara Masihi
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Sara Safiary
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Parvin Abedi
- Midwifery Department, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
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Failure rate of single dose methotrexate in managment of ectopic pregnancy. Obstet Gynecol Int 2015; 2015:902426. [PMID: 25861275 PMCID: PMC4377505 DOI: 10.1155/2015/902426] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/11/2015] [Accepted: 02/23/2015] [Indexed: 11/17/2022] Open
Abstract
Background. One of the treatment modalities for ectopic pregnancy is methotrexate. The purpose of this study is to identify the failure rate of methotrexate in treating patients with ectopic pregnancy as well as the risk factors leading to treatment failure. Methods. A retrospective chart review of 225 patients who received methotrexate as a primary management option for ectopic pregnancy. Failure of single dose of methotrexate was defined as drop of BHCG level less than or equal to 14% in the seventh day after administration of methotrexate. Results. 225 patients had methotrexate. Most of the patients (151 (67%)) received methotrexate based on the following formula: f 50 mg X body surface area. Single dose of methotrexate was successful in 72% (162/225) of the patients. 28% (63/225) were labeled as failure of single dose of methotrexate because of suboptimal drop in BhCG. 63% (40/63) of failure received a second dose of methotrexate, and 37% (23/63) underwent surgical treatment. Among patient who received initial dose of methotrexate, 71% had moderate or severe pain, and 58% had ectopic mass size of more than 4 cm on ultrasound. Conclusion. Liberal use of medical treatment of ectopic pregnancy results in 71% success rate.
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Abstract
Ectopic pregnancy is a high-risk condition that occurs in 2% of reported pregnancies. This percentage is fivefold higher than that registered in the 1970s. Since 1970 there has been a two-fold increase in the ratio of ectopic pregnancies to all reported pregnancies in Hungary and in 2012 7.4 ectopic pregnancies per thousand registered pregnancies were reported. Recently, the majority (80%) of cases can be diagnosed in early stage, and the related mortality objectively decreased in the past few decades to 3.8/10,000 ectopic pregnancies. If a woman with positive pregnancy test has abdominal pain and/or vaginal bleeding the physician should perform a work-up to safely exclude the possibility of ectopic pregnancy. The basis of diagnosis is ultrasonography, especially vaginal ultrasound examination and measurement of the β-subunit of human chorionic gonadotropin. The ultrasound diagnosis is based on the visualization of an ectopic mass rather than the inability to visualize an intrauterine pregnancy. In some questionable cases the diagnostic uterine curettage or laparoscopy may be useful. The actuality of this topic is justified by practical difficulties in obtaining correct diagnosis, especially in the early gestational time.
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Affiliation(s)
- Zoran Belics
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet Szülészeti és Nőgyógyászati Osztály Budapest Köves u. 1. 1204
| | - Balázs Gérecz
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet Szülészeti és Nőgyógyászati Osztály Budapest Köves u. 1. 1204
| | - M György Csákány
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet Szülészeti és Nőgyógyászati Osztály Budapest Köves u. 1. 1204
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Millet I, Bouic-Pages E, Alili C, Curros-Doyon F, Ruyer A, Taourel P. Hémopéritoine, comment gérer ? IMAGERIE DE LA FEMME 2014. [DOI: 10.1016/j.femme.2014.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kusters FJG, Oom DMJ, Van Hof AC. Ampullar ectopic pregnancy following ipsilateral partial isthmic salpingectomy. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s10397-014-0845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Acmaz G, Aksoy H, Bayraktar E, Baser M, Zararsiz G, Ipek Muderris I. Can ratio of blood/curettage material HCG be used as a reliable method for differentiating miscarriage and ectopic pregnancy? Pak J Med Sci 2013; 29:1216-20. [PMID: 24353723 PMCID: PMC3858948 DOI: 10.12669/pjms.295.3391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 07/24/2013] [Accepted: 07/25/2013] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED Objective : There is an increasing rate of ectopic pregnancy with the use of assisted reproductive techniques. There is currently no serum test to differentiate ectopic pregnancy from miscarriage. Early and accurate detection of ectopic pregnancy may prevent the development of complications. The aim of this study was whether the ratio of serum/curettage material hCG could provide us with reliable and early diagnosis in distinguishing miscarriage and ectopic pregnancies and also to measure the diagnostic accuracy rate of this method. METHODS A total of 24 patients were evaluated. Twelve of them were diagnosed as an ectopic pregnancy and 12 of them were diagnosed as a miscarriage. All the patients' diagnoses were confirmed pathologically. Non-of the patient had viable fetus. All participants underwent curettage protocol. Serum and curettage material were obtained at the same time. HCG measurements were done from blood and curettage material. RESULTS Ratio of Blood/Curettage Material HCG provides fast and reliable results within a few hours with 91.7% accuracy rates. CONCLUSION Ratio of blood/curettage material HCG can be used as a reliable method for differentiating ectopic pregnancy and miscarriage.
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Affiliation(s)
- Gokhan Acmaz
- Gokhan Acmaz, MD, Assistant Professor, Dept. of Obstetrics and Gynecology, Kayseri Training and Education Hospital of Medicine, Kayseri, Turkey
| | - Huseyin Aksoy
- Huseyin Aksoy, MD, Dept. of Obstetrics and Gynecology, Kayseri Military Hospital Kayseri, Turkey
| | - Evrim Bayraktar
- Evrim Bayraktar, PhD, Assistant Professor, Dept. of Gynecology and Obstetric Nursing, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muruvvet Baser
- Muruvvet Baser, PhD, RN. (Head of Department), Associate Professor, Dept. of Gynecology and Obstetric Nursing, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Gokmen Zararsiz
- Gokmen Zararsiz, Department of Biostatistics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Iptisam Ipek Muderris
- Dr. Iptisam Ipek Muderris, Professor and Head, Dept. of Obstetrics and Gynecology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Murtaza UI, Ortmann MJ, Mando-Vandrick J, Lee ASD. Management of first-trimester complications in the emergency department. Am J Health Syst Pharm 2013; 70:99-111. [DOI: 10.2146/ajhp120069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Umbreen I. Murtaza
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Melinda J. Ortmann
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | | | - Amy S. D. Lee
- Department of Gynecology-Obstetrics, The Johns Hopkins Hospital, Baltimore
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
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Reid S, Condous G. Is there a need to definitively diagnose the location of a pregnancy of unknown location? The case for "no". Fertil Steril 2013; 98:1085-90. [PMID: 23084010 DOI: 10.1016/j.fertnstert.2012.09.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 11/25/2022]
Abstract
The ability to predict the outcome of a pregnancy of unknown location (PUL) has been extensively studied over the past decade. Between 8%-14% of PULs will develop into ectopic pregnancies (EP), and therefore the need to confirm pregnancy location is not without good reason. Strategies to predict EP in the PUL population have included the use of various maternal serum biomarkers and repeat transvaginal ultrasound (TVS) examinations in order to avoid delaying this diagnosis. These follow-up tests are associated with substantial financial cost to the healthcare system, as well as impacting on maternal anxiety. However, the majority of women with a PUL at follow-up will either have an intra-uterine pregnancy or a spontaneously resolving PUL, and therefore represent low-risk PULs. Most of these low-risk PULs do not need intervention and expectant management has been shown to be safe and not associated with adverse outcomes. Therefore we need consider whether the current strategies to determine pregnancy location are indeed essential for women with a PUL, especially when balancing the additional health care burden with the potential increase in maternal morbidity/mortality associated with delay in diagnosis. This beckons the question, "Do we really need to definitively diagnose pregnancy location in women with a PUL?
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Affiliation(s)
- Shannon Reid
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia.
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Affiliation(s)
- Casey A Boyd
- University of Texas Medical Branch, Galveston, Texas, USA
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17
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Use of magnetic resonance analysis for clinical evaluation of the peripheral area of gestational sac in bleeding and non-bleeding ectopic pregnancy cases. Reprod Med Biol 2011; 11:95-100. [PMID: 29699113 DOI: 10.1007/s12522-011-0114-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 11/19/2011] [Indexed: 10/14/2022] Open
Abstract
Purpose To evaluate preoperative magnetic resonance (MR) imaging features of bleeding and non-bleeding ectopic pregnancy (EP) by comparison with surgical findings. Methods Eighteen suspected EP cases underwent preoperative MR imaging. We classified 8 cases as the bleeding group and 7 cases as the non-bleeding group with or without intra-abdominal bleeding and/or hematoma at the site of EP, and compared, retrospectively, gestational sac (GS)-like structure, particularly the peripheral area of the GS via MR analysis. Excluded were 3 cases that were insufficient for assessing extrauterine GS-like structure: ruptured tubal pregnancy and uterine horn pregnancy. Results GS-like structures were typically observed as low intensity on T1-weighted image (T1WI) and as high intensity on T2-weighted image (T2WI). In non-bleeding cases, most peripheral areas of the GS were of intermediate intensity on T1WI and high intensity on T2WI. Most bleeding cases were of high intensity on T1WI and low to high intensity on T2WI. Furthermore, the peripheral area of the GS was of higher intensity on T1WI with fat suppression than on T1WI. Conclusions It is clear that MR imaging is effective for diagnosis of cases of suspected EP. EP conditions may be predicted by signal intensity of the peripheral area of the GS via MR analysis.
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Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. ACTA ACUST UNITED AC 2011; 37:231-40. [PMID: 21727242 DOI: 10.1136/jfprhc-2011-0073] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Vanitha N Sivalingam
- Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
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19
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Immunological regulation of trophoblast invasion. J Reprod Immunol 2011; 90:21-8. [DOI: 10.1016/j.jri.2011.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/21/2011] [Accepted: 05/02/2011] [Indexed: 12/21/2022]
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Arikan DC, Kiran G, Coskun A, Kostu B. Unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate. Arch Gynecol Obstet 2010; 283:397-9. [PMID: 20376673 DOI: 10.1007/s00404-010-1449-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 03/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Spontaneous tubal twin pregnancy is a rare condition with an incidence of 1 in every 125,000 pregnancies. We present the case of a unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate. CASE A 26-year-old nulliparous woman was admitted to our clinic with a complaint of vaginal bleeding and leftside pelvic pain. Her serum β-human chorionic gonadotropin (β-hCG) level was 18,780 mIU/mL and ultrasound revealed tubal twin pregnancy of 7 weeks' gestation. Because her vital signs were stable and no sign of tubal rupture was present, we performed single-dose (100 mg) methotrexate intramuscularly. In the follow-up, serum β-hCG levels were found to be 7,600 mIU/ml on day 7, 948 mIU/ml on day 20, 126 mIU/ml on day 26 and <10 mIU/ml on day 42. CONCLUSION Methotrexate theraphy may be preferred in tubal twin ectopic pregnancies when the vital signs of the patient are stable and the fetal cardiac activities are negative.
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Affiliation(s)
- Deniz Cemgil Arikan
- Department of Obstetrics and Gynecology, Kahramanmaras Sutcu Imam University, Kahramanmaraş, Turkey.
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Isoardi K. Review article: The use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding. Emerg Med Australas 2009; 21:440-8. [DOI: 10.1111/j.1742-6723.2009.01227.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Poncelet É, Leconte C, Fréart-Martinez É, Laurent N, Lernout M, Bigot J, Robert Y, Closset E, Lucot JP. Aspect échographique et IRM de la grossesse extra-utérine. IMAGERIE DE LA FEMME 2009. [DOI: 10.1016/j.femme.2009.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Casanova BC, Sammel MD, Chittams J, Timbers K, Kulp JL, Barnhart KT. Prediction of outcome in women with symptomatic first-trimester pregnancy: focus on intrauterine rather than ectopic gestation. J Womens Health (Larchmt) 2009; 18:195-200. [PMID: 18991513 DOI: 10.1089/jwh.2008.0896] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Symptoms of vaginal bleeding and abdominal pain are common in cases of ectopic pregnancy (EP), spontaneous abortions (SAB), and complications of an intrauterine pregnancy (IUP). It is important to determine if efforts should focus on differentiating EP from an IUP (IUP + SAB) or a viable IUP from a nonviable gestation (EP + SAB) in women at risk for EP. METHODS This is a retrospective cohort study of women who presented with bleeding or pain or both during the first trimester of pregnancy. The cohort was divided into subjects diagnosed with IUP vs. (EP + SAB). The same cohort was then divided into subjects diagnosed with EP vs. (IUP + SAB). Logistic regression models based on risk factors for both outcomes (EP vs. [IUP + SAB] and IUP vs. [EP + SAB]) were obtained. ROC curves as well as Hosmer-Lemeshow goodness of fit and Akaike's information criterion (AIC) were used. RESULTS Overall, 18.1% (n = 367) of the women were diagnosed with EP, 58.8% (n = 1192) were diagnosed with an SAB, and 23.1% (n = 467) had an ongoing IUP. The area under the ROC curve for the model IUP vs. (EP + SAB) was statistically greater than the model EP vs. (IUP + SAB), p < 0.001. AIC and Hosmer-Lemeshow goodness of fit confirmed the better accuracy of the model comparing IUP vs. (EP + SAB). CONCLUSIONS Information collected at initial presentation from women at risk for EP to be used for building prediction rules should focus on differentiating a viable from a nonviable pregnancy rather than attempting to distinguish an extrauterine from an intrauterine pregnancy. However, this distinction should not affect current clinical care.
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Affiliation(s)
- Bruno C Casanova
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, University of Pennsylvania, Philadelphia, PA 19104, USA
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Mettler L, Sodhi B, Schollmeyer T, Mangeshikar P. Ectopic pregnancy treatment by laparoscopy, a short glimpse. MINIM INVASIV THER 2009; 15:305-10. [PMID: 17062405 DOI: 10.1080/13645700600771942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Ectopic pregnancy is a life-threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein.
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Affiliation(s)
- L Mettler
- Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein, Kiel, Germany.
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Can sonographic endometrial pattern be an early indicator for tubal ectopic pregnancy and related tubal rupture? Arch Gynecol Obstet 2009; 281:189-94. [PMID: 19404658 DOI: 10.1007/s00404-009-1095-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 04/14/2009] [Indexed: 12/27/2022]
Abstract
PURPOSE The present study aims to determine whether sonographic endometrial pattern can be addressed as an early indicator for tubal ectopic pregnancy and related tubal rupture in case ultrasonography reveals no adnexal mass and maternal serum beta human chorionic gonadotropin (HCG) level is below the discriminatory zone (<or=1,000 mIU/mL). METHODS The study evaluated the endometrial features of 441 naturally conceived and asymptomatic first trimester (99 tubal ectopic, 138 failing and 264 normal intrauterine) with maternal serum beta HCG levels<or=1,000 mIU/mL and indeterminate sonographic findings. RESULTS Tubal ectopic, failing intrauterine and normal intrauterine pregnancies are statistically similar in aspect of endometrial thickness. However, trilaminar endometrial pattern was significantly less frequent in failing and normal intrauterine pregnancies but significantly more frequent in ruptured tubal pregnancies. Also the relative risk of tubal rupture is significantly higher in case of trilaminar endometrial pattern. Trilaminar endometrial pattern has a sensitivity of 21.2%, specificity of 93.9%, positive predictive value of 50.0% and negative predictive value of 80.5% for distinguishing tubal ectopic pregnancy. Moreover, the sensitivity, specificity, positive and negative predictive values of the same pattern are computed to be 60.0, 95.7, 85.7 and 84.6%, respectively, in the prediction of ruptured tubal pregnancy. CONCLUSIONS Sonographic appearance of endometrium may be used to predict tubal pregnancy when ultrasonography shows no adnexal mass and maternal serum HCG<or=1,000 mIU/mL. That is, trilaminar pattern may indicate tubal pregnancy and warn about a possible related rupture in case of previous ectopic pregnancy or pelvic surgery.
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Abstract
The incidence of ectopic pregnancies is increasing, which may be related to better diagnostic tools as well as the increasing use of assisted reproductive technologies. However, the signs and symptoms of ectopic pregnancy can be similar to other complications of early pregnancy such as miscarriage. Diagnosis often requires serial human chorionic gonadotropin levels along with ultrasound and, in some cases, dilation and curettage. Once a diagnosis has been made, treatment options include medical therapy with methotrexate and surgery, which can often be performed via the laparoscope. Fertility rates after therapy are similar for both medically and surgically treated patients.
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Affiliation(s)
- Jennifer L Kulp
- University of Pennsylvania Medical Center, Penn Fertility Care, Department of Obstetrics and Gynecology, 3701 Market St. Suite 810, Philadelphia, PA 19104, USA
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27
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Jáné Z, Farkasdi J, Jáger L, Kneffel P, Koppány C, Márkus B, Puskás T. [A rare localisation of ectopic pregnancy--a case of hepatic pregnancy]. Magy Seb 2008; 61:270-2. [PMID: 19028658 DOI: 10.1556/maseb.61.2008.5.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Ectopic pregnancy is a major gynecologic emergency, and remains a life-threatening syndrome. Hepatic pregnancy is an exceptionally rare form of ectopic pregnancy. The authors present a case of a 28 year old woman, who was admitted to hospital with epigastric pain. Diagnostic investigations showed a rare, 16-week-old ectopic pregnancy in the liver. The authors emphasise the importance of early diagnosis and management of ectopic pregnancy in order to reduce maternal mortality.
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Affiliation(s)
- Zoltán Jáné
- Vas Megyei Markusovszky Lajos Altalános, Rehabilitációs és Gyógyfürdo Kórház, Egyetemi Oktatókórház Altalános és Ersebészeti Osztály, 9700 Szombathely, Markusovszky u. 3.
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Madendag Y, Col-Madendag I, Kanat-Pektas M, Danisman N. Predictive power of serum CA-125 and LDH in the outcome of first trimester pregnancies with human chorionic gonadotropin levels below discriminatory zone. Arch Gynecol Obstet 2008; 279:661-6. [DOI: 10.1007/s00404-008-0798-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 09/02/2008] [Indexed: 11/29/2022]
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Dede M, Gezginç K, Yenen M, Ulubay M, Kozan S, Güran S, Başer I. Unilateral tubal ectopic twin pregnancy. Taiwan J Obstet Gynecol 2008; 47:226-8. [PMID: 18603515 DOI: 10.1016/s1028-4559(08)60089-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Güney M, Erdemoglu E, Oral B, Karahan N, Mungan T. Leukemia inhibitory factor (LIF) is immunohistochemically localized in tubal ectopic pregnancy. Acta Histochem 2008; 110:319-23. [PMID: 18258286 DOI: 10.1016/j.acthis.2007.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2007] [Revised: 10/30/2007] [Accepted: 11/02/2007] [Indexed: 11/26/2022]
Abstract
Leukemia inhibitory factor (LIF) is essential for implantation of the embryo in the endometrium. It is not clear whether the blastocyst requires expression of LIF for implantation into tissues other than endometrium. Immunohistochemical localization of LIF was performed in the fallopian tube of 20 women with ectopic pregnancies, 7 women with normal pregnancies and 20 healthy non-pregnant women. Fallopian tubes were evaluated from specimens taken during tubal ligation in normal pregnancies and non-pregnant fertile women or at operation for tubal surgery in ectopic pregnancies. Biopsies were assayed by immunohistochemistry. Semi-quantitative immunohistochemical reaction scores (IRS) were used for immunohistochemical analyses. Immunolabeling of LIF was detected in the surface epithelium and stroma of fallopian tubes in all subjects. IRS score in the epithelium and stroma of non-pregnant women and women with intrauterine pregnancy were similar (p>0.05). However, women with ectopic pregnancy had significantly increased labeling of LIF compared to others (p<0.05). Immunohistochemical labeling of LIF in the fallopian tube was found to be increased in ectopic pregnancies compared to non-pregnant and healthy pregnant controls. This may indicate a role of LIF in the ectopic implantation of embryos.
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Abstract
A case report of ovarian pregnancy is presented. A 38 year old woman, gravida 3 para 2, was admitted to the hospital for suspected ectopic pregnancy, with vaginal bleeding at 12 weeks after her last menstrual period, associated with pelvic pain. An ultra-sonography led to the diagnosis of ovarian right ectopic pregnancy with dead fetus associated with a compartmentalized hemoperitoneum. Unilateral oophorectomy was carried out by laparotomy. Histological studies confirmed an ovarian pregnancy.
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Affiliation(s)
- F Naghshvar
- Department of Pathobiology, Mazandaran University of Medical Science, Iran
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33
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Tamai K, Koyama T, Togashi K. MR features of ectopic pregnancy. Eur Radiol 2007; 17:3236-46. [PMID: 17882426 DOI: 10.1007/s00330-007-0751-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Revised: 08/11/2007] [Accepted: 08/20/2007] [Indexed: 10/22/2022]
Abstract
Ectopic pregnancy (EP), in which a fertilized ovum implants outside the uterine cavity, is the leading cause of pregnancy-related death in the first trimester. EP is usually suspected by a positive pregnancy test and an empty uterus on transvaginal sonography (TVS). Although TVS is the initial modality of choice, it may occasionally fail to demonstrate the implantation site. When TVS findings are indeterminate, magnetic resonance imaging (MRI) may provide better delineation of the focus of EP owing to its excellent tissue contrast. The key MRI features of EP include gestational sac (GS)-like structures that typically appear as a cystic sac-like structure, frequently associated with surrounding acute hematoma of distinct low intensity on T2-weighted images. In tubal pregnancy, an enhanced tubal wall on postcontrast images may be another diagnostic finding. Ruptured EP is inevitably associated with acute hematoma outside these structures. In intrauterine EP, recognition of the relationship between GS-like structure and the myometrium can aid in differentiating from normal pregnancy. Diagnostic pitfalls include heterotopic pregnancy, decidual changes in endometrial cyst and theca lutein cysts mimicking GS-like structures. Knowledge of a spectrum of clinical and MRI features of EP is essential for establishing an accurate diagnosis and determining appropriate management.
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Affiliation(s)
- Ken Tamai
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Lim JE, Kim T, Lee NW, Oh MJ, Seol HJ, Jung NH, Park SH, Jung SE, Park IH, Kim HJ. Ultrasonographic endometrial features in tubal pregnancy: are they predictive factors of successful medical treatment? ULTRASOUND IN MEDICINE & BIOLOGY 2007; 33:714-9. [PMID: 17412483 DOI: 10.1016/j.ultrasmedbio.2006.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Revised: 10/24/2006] [Accepted: 10/31/2006] [Indexed: 05/14/2023]
Abstract
The aim of this study was to explain possible relationships in cases of ectopic pregnancy between sonographic endometrial features and treatment outcome following methotrexate (MTX) injection. A total of 157 cases of unruptured tubal pregnancy were diagnosed and treated systemically with MTX. The sonographic endometrial pattern, endometrial thickness and treatment outcome were retrospectively analyzed. There were four types of endometrial patterns: these were trilaminar, homogeneous, heterogeneous and pseudosac. Success rates following MTX treatment were different for each group: these were 64.7%, 78.4%, 50.0% and 46.2%, respectively (p = 0.0129). And the risk of treatment failure was increased 3.64 times (95% CI 1.56 to 8.49) in heterogeneous thick pattern and 4.24 times (95% CI 1.18 to 15.23) in pseudosac pattern. In conclusion, when tubal pregnancy was seen in a pseudogestational sac pattern or a heterogeneous pattern, the failure rate of medical treatment was increased. This can serve as a reference for considering the decision about medical treatment in women with unruptured tubal pregnancy.
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Affiliation(s)
- Ji Eun Lim
- Department of Obstetrics and Gynecology, Ansan Hospital, Ansan City, South Korea
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Lubner M, Menias C, Rucker C, Bhalla S, Peterson CM, Wang L, Gratz B. Blood in the belly: CT findings of hemoperitoneum. Radiographics 2007; 27:109-25. [PMID: 17235002 DOI: 10.1148/rg.271065042] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hemoperitoneum may occur in various emergent conditions. In the trauma setting, evidence of intraperitoneal blood depicted at computed tomography (CT) should lead the radiologist to conduct a careful search of images for the injured visceral organ (the liver or spleen). Specific CT signs, such as a sentinel clot or extravasation of intravascular contrast material, may indicate the source of bleeding and help direct management. In addition, the configuration of accumulated blood may help identify the injured organ; for example, triangular fluid collections are observed in the mesentery most often in the setting of bowel or mesenteric injury. Less commonly, hemoperitoneum may have a nontraumatic origin. Iatrogenic hemoperitoneum may occur as a complication of surgery or other interventional procedures in the abdominal cavity or as a result of anticoagulation therapy. Hemoperitoneum also may be seen in the setting of blood dyscrasias such as hemophilia and polycythemia vera. Tumor-associated hemorrhage, which most often occurs in hepatocellular carcinoma, hepatic adenoma, or vascular metastatic disease, also may produce hemoperitoneum. Other potential causes of nontraumatic hemoperitoneum are gynecologic conditions such as hemorrhage or rupture of an ovarian cyst and rupture of the gestational sac in ectopic pregnancy, and hepatic hematoma in syndromic hemolysis with elevated liver enzymes and low platelet count (HELLP syndrome). Vascular lesions (visceral artery aneurysms and pseudoaneurysms) that occur in systemic vascular diseases such as Ehlers-Danlos syndrome or in pancreatitis are another less common source of hemoperitoneum.
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Affiliation(s)
- Meghan Lubner
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Box 8131, St Louis, MO 63110, USA.
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Erwin EA, Counselman FL. Ectopic pregnancy presenting as rectal pain. Am J Emerg Med 2007; 25:221-2. [PMID: 17276825 DOI: 10.1016/j.ajem.2006.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 06/05/2006] [Indexed: 11/29/2022] Open
Affiliation(s)
- Eleanor A Erwin
- Department of Emergency Medicine, Eastern Virginia Medical School and Emergency, Physicians of Tidewater, Norfolk, VA 23507, USA
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Hamman AK, Wang NE, Chona S. The pregnant adolescent with vaginal bleeding: etiology, diagnosis, and management. Pediatr Emerg Care 2006; 22:761-7; quiz 768-9. [PMID: 17047481 DOI: 10.1097/01.pec.0000238740.06909.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alyssa K Hamman
- Department of Anesthesiology, Stanford University Hospital, Stanford, CA, USA
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38
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The Challenge of Ectopic Pregnancy. J Nurse Pract 2006. [DOI: 10.1016/j.nurpra.2006.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
An ectopic pregnancy is a life-threatening form of pregnancy that is increasing in frequency especially in adolescents. Whenever a woman of childbearing age, including adolescents, presents with abdominal pain, the diagnosis of ectopic pregnancy must be considered as a possibility because if it is not diagnosed and treated expediously and appropriately, there will be considerable morbidity and mortality. Methotrexate has been shown to be effective in the management of ectopic pregnancy, but few reports are described in the literature regarding its use in teenagers. We report the cases of 2 adolescents with ectopic pregnancies who were treated successfully with methotrexate.
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Affiliation(s)
- Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical & Mental Health Center, Bronx, NY 10451, USA.
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40
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Abstract
Women who present with pain and bleeding in the first trimester are at risk for ectopic pregnancy, a life-threatening condition. Conditions that predispose a woman to ectopic pregnancy are damaged fallopian tubes from prior tubal surgery or previous pelvic infection, smoking, and conception using assisted reproduction. Many women without risk factors can develop an ectopic pregnancy. A diagnostic algorithm that includes the use of transvaginal ultrasonography, human chorionic gonadotropin (hCG) concentrations, and, sometimes, uterine curettage can definitively diagnose women at risk in a timely manner. The absence of an intrauterine pregnancy above an established cut point of hCG is consistent with an abnormal pregnancy but does not distinguish a miscarriage from an ectopic pregnancy. When the initial hCG value is low, serial hCG values can be used to determine whether a gestation is potentially viable or spontaneously resolving. The minimal rise in hCG for a viable pregnancy is 53% in 2 days. The minimal decline of a spontaneous abortion is 21-35% in 2 days, depending on the initial level. A rise or fall in serial hCG values that is slower than this is suggestive of an ectopic pregnancy. Women diagnosed with an unruptured ectopic pregnancy are potential candidates for medical management with methotrexate. Intramuscular injection with methotrexate can be used to safely treat an ectopic pregnancy with success rates, tubal patency rates, and future fertility that are similar to those obtained with conservative surgery. Success rates using methotrexate are inversely rated to baseline hCG values and are higher using "multidose" compared with "single-dose" regimens. Surgical treatment may be conservative or definitive and should be attempted in most cases via laparoscopy.
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Affiliation(s)
- Beata E Seeber
- Department of Obstetrics and Gynecology, Penn Fertility Care, Philadelphia, PA 19003, USA
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41
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Abstract
This article discusses the endocrinology of ectopic pregnancy.
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Affiliation(s)
- Erkut Attar
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Istanbul University, Istanbul Medical School, Capa, Istanbul, 34093, Turkey.
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42
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Samraj GPN, Curry RW. Acute pelvic pain: Evaluation and management. ACTA ACUST UNITED AC 2004; 30:173-84. [PMID: 15793318 DOI: 10.1007/s12019-004-0015-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 09/13/2004] [Indexed: 10/23/2022]
Abstract
Acute pelvic pain in women is often a diagnostic dilemma. Obstetrical, gynecological, urological or gastrointestinal causes must be considered. Stabilization, immediate therapy and early consultation are often indicated. If no etiology is found, conservative management with frequent re-evaluation is adequate.
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Affiliation(s)
- George P N Samraj
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL 32601, USA
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Mena J, López-Hidalgo M, Gordillo R, Rodríguez A, Cóndor L. Embarazo ectópico tubárico tras programa FIV embarazo ectópico abdominal. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2004. [DOI: 10.1016/s0210-573x(04)77354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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