Nanomedicines for Improved Management of Ectopic Pregnancy: A Narrative Review

Ectopic pregnancy (EP) - the implantation of an embryo outside of the endometrial cavity, often in the fallopian tube - is a significant contributor to maternal morbidity and leading cause of maternal death due to hemorrhage in first trimester. Current diagnostic modalities including human chorionic gonadotropin (hCG) quantification and ultrasonography are effective, but may still misdiagnose EP at initial examination in many cases. Depending on the patient's hemodynamic stability and gestational duration of the pregnancy, as assessed by history, hCG measurement and ultrasonography, management strategies may include expectant management, chemotherapeutic treatment using methotrexate (MTX), or surgical intervention. While these strategies are largely successful, expectant management may result in tubal rupture if the pregnancy does not resolve spontaneously; MTX administration is not always successful and may induce significant side effects; and surgical intervention may result in loss of the already-damaged fallopian tube, further hampering the patient's subsequent attempts to conceive. Nanomaterial-based technologies offer the potential to enhance delivery of diagnostic imaging contrast and therapeutic agents to more effectively and safely manage EP. The purpose of this narrative review is to summarize the current state of nanomedicine technology dedicated to its potential to improve both the diagnosis and treatment of EP.

β-Human Chorionic Gonadotropin Dynamics in Early Gestational Events: A Practical and Updated Reappraisal

In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the β-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.

The association between human chorionic gonadotropin and adverse pregnancy outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the association between human chorionic gonadotropin and adverse pregnancy outcomes.

DATA SOURCES

Medline, Embase, PubMed, and Cochrane were searched in November 2021 using Medical Subject Headings (MeSH) and relevant key words.

STUDY ELIGIBILITY CRITERIA

This analysis included published full-text studies of pregnant women with serum human chorionic gonadotropin testing between 8 and 28 weeks of gestation, investigating fetal outcomes (fetal death in utero, small for gestational age, preterm birth) or maternal factors (hypertension in pregnancy: preeclampsia, pregnancy-induced hypertension, placental abruption, HELLP syndrome, gestational diabetes mellitus).

METHODS

Studies were extracted using REDCap software. The Newcastle-Ottawa scale was used to assess for risk of bias. Final meta-analyses underwent further quality assessment using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) method.

RESULTS

A total of 185 studies were included in the final review, including the outcomes of fetal death in utero (45), small for gestational age (79), preterm delivery (62), hypertension in pregnancy (107), gestational diabetes mellitus (29), placental abruption (17), and HELLP syndrome (2). Data were analyzed separately on the basis of categorical measurement of human chorionic gonadotropin and human chorionic gonadotropin measured on a continuous scale. Eligible studies underwent meta-analysis to generate a pooled odds ratio (categorical human chorionic gonadotropin level) or difference in medians (human chorionic gonadotropin continuous scale) between outcome groups. First-trimester low human chorionic gonadotropin levels were associated with preeclampsia and fetal death in utero, whereas high human chorionic gonadotropin levels were associated with preeclampsia. Second-trimester high human chorionic gonadotropin levels were associated with fetal death in utero and preeclampsia.

CONCLUSION

Human chorionic gonadotropin levels are associated with placenta-mediated adverse pregnancy outcomes. Both high and low human chorionic gonadotropin levels in the first trimester of pregnancy can be early warning signs of adverse outcomes. Further analysis of human chorionic gonadotropin subtypes and pregnancy outcomes is required to determine the diagnostic utility of these findings in reference to specific cutoff values.

Diagnostic value of a urine test in pregnancy of unknown location

BACKGRO

Pregnancy of unknown location (PUL) is a term used when there is a positive pregnancy test but no sonographic evidence for an intrauterine pregnancy (IUP) or ectopic pregnancy (EP). This term is a classification and not a final diagnosis.

OBJECTIVE

This study aimed to evaluate the diagnostic value of the Inexscreen test on the outcome of patients with pregnancies of unknown location.

STUDY DESIGN

In this prospective study, a total of 251 patients with a diagnosis of pregnancy of unknown location at the gynecologic emergency department of the La Conception Hospital, Marseille, France, between June 2015 and February 2019 were included. The Inexscreen (semiquantitative determination of intact human urinary chorionic gonadotropin) test was performed on patients with a diagnosis of pregnancy of unknown location. They participated in the study after information and consent collection. The main outcome measures (sensitivity, specificity, predictive values, and the Youden index) of Inexscreen were calculated for the diagnosis of abnormal pregnancy (nonprogressive pregnancy) and ectopic pregnancy.

RESULTS

The sensitivity and specificity of Inexscreen for the diagnosis of abnormal pregnancy in patients with pregnancy of unknown location were 56.3% (95% confidence interval, 47.0%-65.1%) and 62.8% (95% confidence interval, 53.1%-71.5%), respectively. The sensitivity and specificity of Inexscreen for the diagnosis of ectopic pregnancy in patients with pregnancy of unknown location were 81.3% (95% confidence interval, 57.0%-93.4%) and 55.6% (95% confidence interval, 48.6%-62.3%), respectively. The positive predictive value and negative predictive value of Inexscreen for ectopic pregnancy were 12.9% (95% confidence interval, 7.7%-20.8%) and 97.4% (95% confidence interval, 92.5%-99.1%), respectively.

CONCLUSION

Inexscreen is a rapid, non-operator-dependent, noninvasive, and inexpensive test that allows the selection of patients at high risk of ectopic pregnancy in case of pregnancy of unknown location. This test allows an adapted follow-up according to the technical platform available in a gynecologic emergency service.

Middle-East obgyn graduate education (MOGGE) foundation practice guidelines: diagnostic approach to pregnancy of unknown location: practice guideline no. 03-O-21

Background

Pregnancy of unknown location (PUL) is a term used to describe failure of visualization of intrauterine or extrauterine gestational sac in a woman with a positive pregnancy test.

Body of the abstract

Ectopic pregnancy (EP) accounts for 1–2 % of all pregnancies. EP contributes to maternal mortality of a known cause by 4% in developed countries. However, case fatality rate may be 10 times higher in low-resource countries. This may be attributed to delayed diagnosis and lack of resources. PUL is a temporary term that may eventually lead to diagnosis of viable intrauterine pregnancy, pregnancy loss, or more seriously, EP.

Conclusion

This guideline appraises current evidence on assessment of PUL and early diagnosis of EP particularly in low-resource settings.

Pregnancy of unknown location: external validation of the hCG-based M6NP and M4 prediction models in an emergency gynaecology unit

OBJECTIVE

To investigate if M6NP predicting ectopic pregnancy (EP) among women with pregnancy of unknown location (PUL) is valid in an emergency gynaecology setting and comparing it with its predecessor M4.

DESIGN

Retrospective cohort study.

SETTING

University Hospital.

PARTICIPANTS

Women with PUL.

METHODS

All consecutive women with a PUL during a study period of 3 years were screened for inclusion. Risk prediction of an EP was based on two serum human chorionic gonadotropin (hCG) levels taken at least 24 hours and no longer than 72 hours apart.

MAIN OUTCOME MEASURES

The area under the ROC curve (AUC) expressed the ability of a model to distinguish an EP from a non-EP (discrimination). Calibration assessed the agreement between the predicted risk of an EP and the true risk (proportion) of EP. The proportion of EPs and non-EPs classified as high risk assessed the model's sensitivity and false positive rate (FPR). The proportion of non-EPs among women classified as low risk was the model's negative predictive value (NPV). The clinical utility of a model was evaluated with decision curve analysis.

RESULTS

1061 women were included in the study, of which 238 (22%) had a final diagnosis of EP. The AUC for EP was 0.85 for M6NP and 0.81 for M4. M6NP made accurate risk predictions of EP up to predictions of 20% but thereafter risks were underestimated. M4 was poorly calibrated up to risk predictions of 40%. With a 5% threshold for high risk classification the sensitivity for EP was 95% for M6NP, the FPR 50% and NPV 97%. M6NP had higher sensitivity and NPV than M4 but also a higher FPR. M6NP had utility at all thresholds as opposed to M4 that had no utility at thresholds≤5%.

CONCLUSIONS

M6NP had better predictive performance than M4 and is valid in women with PUL attending an emergency gynaecology unit. Our results can encourage implementation of M6NP in related yet untested clinical settings to effectively support clinical decision-making.

[Retrospective validation of a model to predict the outcome of pregnancies of unknown location]

OBJECTIVE

The prediction model M6 classifies pregnancy of unknown location (PUL) into a low-risk or a high-risk group in developing ectopic pregnancy (EP). The aim of this study was to validate the two-step M6 model's ability to classify PUL in French women.

MATERIAL AND METHODS

All women with a diagnosis of PUL over a year were included in this single center retrospective study. Patients with a diagnosis of EP at the first consultation of with incomplete data were excluded. For each patient, the M6 model calculator was used to classified them into "high risk of EP" and "low risk of EP" group. The reference standard was the final diagnostic: failed PUL (FPUL), intrauterine pregnancy (IUP) of EP. The statistical measures of the test's performance were calculated.

RESULTS

Over the period, 255 women's consulted for a PUL, 197 has been included in the study. Final diagnosis were: 94 FPUL (94/197; 47.7%), 74 IUP (74/197; 37.6%) et 29 EP (29/197; 14.7%). The first step of the M6 model classified 16 women in the FPUL group of which 15 (15/16; 93.7%) correctly. The second step of the M6 model classified 181 women: 90 (90/181; 49.7%) in the "high risk of EP" group of which 63 (63/90; 70%) were FPUL/IUP and 27 (27/90; 30%) were EP. 91 (91/181; 50.3%) was classified in the "low risk of EP" group of which 90 (90/91; 98.9%) were FPUL/IUP and 1 (1/91; 1.1%) were EP. EP were correctly classified with sensitivity of 96.4%, negative predictive value of 98.9%, specificity of 58.8% and positive predictive value of 30.0%.

CONCLUSIONS

The prediction model of PUL M6 classified EP in "high risk of EP group" with a sensitivity of 96.4%. It classified 50.3% of PUL in a "low risk of EP" group with a negative predictive value of 98.9%.

Evaluating cut-off levels for progesterone, β human chorionic gonadotropin and β human chorionic gonadotropin ratio to exclude pregnancy viability in women with a pregnancy of unknown location: A prospective multicenter cohort study

INTRODUCTION

There is no global agreement on how to best determine pregnancy of unknown location viability and location using biomarkers. Measurements of progesterone and β human chorionic gonadotropin (βhCG) are still used in clinical practice to exclude the possibility of a viable intrauterine pregnancy (VIUP). We evaluate the predictive value of progesterone, βhCG, and βhCG ratio cut-off levels to exclude a VIUP in women with a pregnancy of unknown location.

MATERIAL AND METHODS

This was a secondary analysis of prospective multicenter study data of consecutive women with a pregnancy of unknown location between January 2015 and 2017 collected from dedicated early pregnancy assessment units of eight hospitals. Single progesterone and serial βhCG measurements were taken. Women were followed up until final pregnancy outcome between 11 and 14 weeks of gestation was confirmed using transvaginal ultrasonography: (1) VIUP, (2) non-viable intrauterine pregnancy or failed pregnancy of unknown location, and (3) ectopic pregnancy or persisting pregnancy of unknown location. The predictive value of cut-off levels for ruling out VIUP were evaluated across a range of values likely to be encountered clinically for progesterone, βhCG, and βhCG ratio.

RESULTS

Data from 2507 of 3272 (76.6%) women were suitable for analysis. All had data for βhCG levels, 2248 (89.7%) had progesterone levels, and 1809 (72.2%) had βhCG ratio. The likelihood of viability falls with the progesterone level. Although the median progesterone level associated with viability was 59 nmol/L, VIUP were identified with levels as low as 5 nmol/L. No single βhCG cut-off reliably ruled out the presence of viability with certainty, even when the level was more than 3000 IU/L, there were 39/358 (11%) women who had a VIUP. The probability of viability decreases with the βhCG ratio. Although the median βhCG ratio associated with viability was 2.26, VIUP were identified with ratios as low as 1.02. A progesterone level below 2 nmol/L and βhCG ratio below 0.87 were unlikely to be associated with viability but were not definitive when considering multiple imputation.

CONCLUSIONS

Cut-off levels for βhCG, βhCG ratio, and progesterone are not safe to be used clinically to exclude viability in early pregnancy. Although βhCG ratio and progesterone have slightly better performance in comparison, single βhCG used in this manner is highly unreliable.

Diagnosis and Management of Ectopic Pregnancy: A Comparative Review of Major National Guidelines

Importance

Ectopic pregnancies (EPs) represent a severe early pregnancy complication that is associated with increased risks of maternal morbidity and mortality. Over the years, there has been a significant reduction in the mortality from this complication by improving the diagnostic tools and the treatment options.

Objective

The aim of this study was to review and compare the recommendations from published guidelines on this potentially fatal condition.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence on EP was carried out.

Results

All the guidelines point out the crucial role of sonography in the prompt diagnosis of EP and describe similar sonographic findings. There is a consensus on the indications and contraindications to the use of methotrexate, the post-treatment surveillance, and the criteria of expectant management. The indications for a surgical approach are not well established, although the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence agree that a laparoscopy is preferred to laparotomy for hemodynamically stable patients. The latter is considered a better option only in emergency conditions. However, there is controversy in the recommended methotrexate protocols and the evaluation of β-human chorionic gonadotrophin and progesterone levels.

Conclusion

It is of paramount importance to build consistent international protocols, so as to help clinicians all over the world diagnose EPs in the most timely and accurate way and subsequently treat them effectively as a nonurgent medical condition, with the intention to lower the mortality and morbidity rate.

The Use of Single Dose Methotrexate in the Management of Ectopic Pregnancy and Pregnancy of Unknown Location: 10 Years’ Experience in a Tertiary Center

Objective

To study factors associated with the success of single dose methotrexate (MTX) treatment in women with ectopic pregnancy.

Methods

This is a retrospective study of women (n=110) with ectopic pregnancy and treated with single dose of MTX. The clinical presentations, transvaginal sonography (TVS) findings, pretreatment beta-human chorionic gonadotropin (β-HCG), and progesterone values were compared between the treatment success (Group S) and treatment failure (Group F) groups.

Results

The overall success rate of treatment with single dose of MTX was 75.45%. The majority of patients in both groups presented with pain and bleeding (~55%), and bleeding only was the presenting symptom in about 20% of patients. Only 3 patients (3.61%) in Group S required a repeat dose of MTX. In contrast, 51.8% of the Group F patients required a repeat dose. The mean pretreatment β-HCG level was 2.3 times higher in Group F than in Group S (1734±1684 vs 4036±2940 IU/L). The data showed a β-HCG level of 3924IU/L as a suitable cut-off value with 76.19% sensitivity and 62.5% specificity to predict MTX treatment success. History of ectopic pregnancy had no relation with success/treatment failure or a repeat dose. None of the TVS findings were related to the outcome of the treatment, whereas pretreatment HCG level was a significant predictor.

Conclusion

The single dose MTX treatment was successful in 75.45% (83/110) of cases, with 3.61% (3/83) requiring a repeat dose of the drug. Pretreatment β-HCG level is a significant predictor of the treatment outcome.

External validation of models to predict the outcome of pregnancies of unknown location: a multicentre cohort study

Objective

To validate externally five approaches to predict ectopic pregnancy (EP) in pregnancies of unknown location (PUL): the M6P and M6NP risk models, the two‐step triage strategy (2ST, which incorporates M6P), the M4 risk model, and beta human chorionic gonadotropin ratio cut‐offs (BhCG‐RC).

Design

Secondary analysis of a prospective cohort study.

Setting

Eight UK early pregnancy assessment units.

Population

Women presenting with a PUL and BhCG >25 IU/l.

Methods

Women were managed using the 2ST protocol: PUL were classified as low risk of EP if presenting progesterone ≤2 nmol/l; the remaining cases returned 2 days later for triage based on M6P. EP risk ≥5% was used to classify PUL as high risk. Missing values were imputed, and predictions for the five approaches were calculated post hoc. We meta‐analysed centre‐specific results.

Main outcome measures

Discrimination, calibration and clinical utility (decision curve analysis) for predicting EP.

Results

Of 2899 eligible women, the primary analysis excluded 297 (10%) women who were lost to follow up. The area under the ROC curve for EP was 0.89 (95% CI 0.86–0.91) for M6P, 0.88 (0.86–0.90) for 2ST, 0.86 (0.83–0.88) for M6NP and 0.82 (0.78–0.85) for M4. Sensitivities for EP were 96% (M6P), 94% (2ST), 92% (N6NP), 80% (M4) and 58% (BhCG‐RC); false‐positive rates were 35%, 33%, 39%, 24% and 13%. M6P and 2ST had the best clinical utility and good overall calibration, with modest variability between centres.

Conclusions

2ST and M6P performed best for prediction and triage in PUL.

Tweetable abstract

The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.

The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.

External validation of risk prediction model M4 in an Australian population: Rationalising the management of pregnancies of unknown location

BACKGROUND

The prediction model M4 can successfully classify pregnancy of unknown location (PUL) into a low- or high-risk group in developing ectopic pregnancy. M4 was validated in UK centres but in very few other countries outside UK.

AIM

To validate the M4 model's ability to correctly classify PULs in a cohort of Australian women.

MATERIALS AND METHODS

A retrospective analysis of women classified with PUL, attending a Sydney-based teaching hospital between 2006 and 2018. The reference standard was the final characterisation of PUL: failed PUL (FPUL) or intrauterine pregnancy (IUP; low risk) vs ectopic pregnancy (EP) or persistent PUL (PPUL; high risk). Each patient was entered into the M4 model calculator and an estimated risk of FPUL/IUP or EP/PPUL was recorded. Diagnostic accuracy of the M4 model was evaluated.

RESULTS

Of 9077 consecutive women who underwent transvaginal sonography, 713 (7.9%) classified with a PUL. Six hundred and seventy-seven (95.0%) had complete study data and were included. Final outcomes were: 422 (62.3%) FPULs, 150 (22.2%) IUPs, 105 (15.5%) EPs and PPULs. The M4 model classified 455 (67.2%) as low-risk PULs of which 434 (95.4%) were FPULs/IUPs and 21 (4.6%) were EPs or PPULs. EPs/PPULs were correctly classified with sensitivity of 80.0% (95% CI 71.1-86.5%), specificity of 75.9% (95% CI 72.2-79.3%), positive predictive value of 37.8% (95% CI 33.8-42.1%) and negative predictive value of 95.3% (95% CI 93.1-96.9%).

CONCLUSIONS

We have externally validated the prediction model M4. It classified 67.2% of PULs as low risk, of which 95.4% were later characterised as FPULs or IUPs while still classifying 80.0% of EPs as high risk.

Predicting Ectopic Pregnancy Using Human Chorionic Gonadotropin (hCG) Levels and Main Cause of Infertility in Women Undergoing Assisted Reproductive Treatment: Retrospective Observational Cohort Study

Background

Ectopic pregnancy (EP) is a serious complication of assisted reproductive technology (ART). However, there is no acknowledged mathematical model for predicting EP in the ART population.

Objective

The goal of the research was to establish a model to tailor treatment for women with a higher risk of EP.

Methods

From December 2015 to July 2016, we retrospectively included 1703 women whose serum human chorionic gonadotropin (hCG) levels were positive on day 21 (hCG21) after fresh embryo transfer. Multivariable multinomial logistic regression was used to predict EP, intrauterine pregnancy (IUP), and biochemical pregnancy (BCP).

Results

The variables included in the final predicting model were (hCG21, ratio of hCG21/hCG14, and main cause of infertility). During evaluation of the model, the areas under the receiver operating curve for IUP, EP, and BCP were 0.978, 0.962, and 0.999, respectively, in the training set, and 0.963, 0.942, and 0.996, respectively, in the validation set. The misclassification rates were 0.038 and 0.045, respectively, in the training and validation sets. Our model classified the whole in vitro fertilization/intracytoplasmic sperm injection–embryo transfer population into four groups: first, the low-risk EP group, with incidence of EP of 0.52% (0.23%-1.03%); second, a predicted BCP group, with incidence of EP of 5.79% (1.21%-15.95%); third, a predicted undetermined group, with incidence of EP of 28.32% (21.10%-35.53%), and fourth, a predicted high-risk EP group, with incidence of EP of 64.11% (47.22%-78.81%).

Conclusions

We have established a model to sort the women undergoing ART into four groups according to their incidence of EP in order to reduce the medical resources spent on women with low-risk EP and provide targeted tailor-made treatment for women with a higher risk of EP.

Triaging women with pregnancy of unknown location using two-step protocol including M6 model: clinical implementation study

OBJECTIVE

The M6 risk-prediction model was published as part of a two-step protocol using an initial progesterone level of ≤ 2 nmol/L to identify probable failing pregnancies (Step 1) followed by the M6 model (Step 2). The M6 model has been shown to have good triage performance for stratifying women with a pregnancy of unknown location (PUL) as being at low or high risk of harboring an ectopic pregnancy (EP). This study validated the triage performance of the two-step protocol in clinical practice by evaluating the number of protocol-related adverse events and how effectively patients were triaged.

METHODS

This was a prospective multicenter interventional study of 3272 women with a PUL, carried out between January 2015 and January 2017 in four district general hospitals and four university teaching hospitals in the UK. The final pregnancy outcome was defined as: a failed PUL (FPUL), an intrauterine pregnancy (IUP) or an EP (including persistent PUL (PPUL)). FPUL and IUP were grouped as low-risk and EP/PPUL as high-risk PUL. Serum progesterone and human chorionic gonadotropin (hCG) levels were measured at presentation in all patients. If the initial progesterone level was ≤ 2 nmol/L, patients were discharged and were asked to have a follow-up urine pregnancy test in 2 weeks to confirm a negative result. If the progesterone level was > 2 nmol/L or a measurement had not been taken, hCG level was measured again at 48 h and results were entered into the M6 model. Patients were managed according to the outcome predicted by the protocol. Those classified as 'low risk, probable FPUL' were advised to perform a urine pregnancy test in 2 weeks and those classified as 'low risk, probable IUP' were invited for a scan a week later. When a woman with a PUL was classified as high risk (i.e. risk of EP ≥ 5%) she was reviewed clinically within 48 h. One center used a progesterone cut-off of ≤ 10 nmol/L and its data were analyzed separately. If the recommended management protocol was not adhered to, this was recorded as a protocol deviation and classified as: unscheduled visit for clinician reason, unscheduled visit for patient reason or incorrect timing of blood test or ultrasound scan. The classifications outlined in the UK Good Clinical Practice (GCP) guidelines were used to evaluate the incidence of adverse events. Data were analyzed using descriptive statistics.

RESULTS

Of the 3272 women with a PUL, 2625 were included in the final analysis (317 met the exclusion criteria or were lost to follow-up, while 330 were evaluated using a progesterone cut-off of ≤ 10 nmol/L). Initial progesterone results were available for 2392 (91.1%) patients. In Step 1, 407 (15.5%) patients were classified as low risk (progesterone ≤ 2 nmol/L), of whom seven (1.7%) were ultimately diagnosed with an EP. In 279 of the remaining 2218 women with a PUL, the M6 model was not applied owing to protocol deviation or because the outcome was already known (usually on the basis of an ultrasound scan) before a second hCG reading was taken; of these patients, 30 were diagnosed with an EP. In Step 2, 1038 women with a PUL were classified as low risk, of whom eight (0.8%) had a final outcome of EP. Of 901 women classified as high risk at Step 2, 275 (30.5%) had an EP. Therefore, 275/320 (85.9%) EPs were correctly classified as high risk. Overall, 1445/2625 PUL (55.0%) were classified as low risk, of which 15 (1.0%) were EP. None of these cases resulted in a ruptured EP or significant clinical harm. Sixty-two women participating in the study had an adverse event, but no woman had a serious adverse event as defined in the UK GCP guidelines.

CONCLUSIONS

This study has shown that the two-step protocol incorporating the M6 model effectively triaged the majority of women with a PUL as being at low risk of an EP, minimizing the follow-up required for these patients after just two visits. There were few misclassified EPs and none of these women came to significant clinical harm or suffered a serious adverse clinical event. The two-step protocol incorporating the M6 model is an effective and clinically safe way of rationalizing the management of women with a PUL. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

The diagnostic role of the β-hCG discriminatory zone combined with the endometrial pattern for ectopic pregnancy in Chinese women

Previous studies have regarded the discriminatory serum β-hCG zone (DSZ) as a valuable tool for the diagnosis of ectopic pregnancy (EP). However, the wide range of the DSZ makes achieving a clinical diagnosis of EP difficult, and these reports do not indicate whether the DSZ is suitable for an EP diagnosis in Chinese women. Several studies have indicated that the endometrial pattern in patients with EPs is different from that in patients with intrauterine pregnancies (IUPs). The aims of this study were to define the DSZ cutoff value for Chinese women, test whether the endometrial pattern is a suitable predictor for EP, and assess the diagnostic value of these indicators. We enrolled participants with IUPs or EPs with abdominal pain and/or vaginal bleeding, and serum β-hCG level measurements and transvaginal ultrasound (TVS) were performed to assess the diagnostic value of the indicators for EP. The sensitivity and specificity for identifying an EP were improved by combining the DSZ, endometrial thickness and trilaminar pattern indexes. The results of this study might be helpful toward providing further options for the diagnosis of EP, especially for patients without hemoperitoneum or colporrhagia.

ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy

Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence.

Prospective observational cohort study: Computational models for early prediction of ongoing pregnancy in fresh IVF/ICSI-ET protocols

PURPOSE

This study sought to identify the significant factors related to ongoing pregnancy (OP) and to discover the most reliable model to distinguish OP from non-OP in early gestational age.

METHODS

A total of 1650 cycles were enrolled in this study. Univariate Logistic Regression was used to identify the predictors included in multivariable analysis. The dataset was then randomly split into training set and test set with proportion of 70% and 30%. Forward stepwise multivariable logistic regression with 5-fold cross validation was used to build the final mathematic model. The performance of the model was determined by the arguments of test set. The area under receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and misclassification rate (MR) were then calculated for model evaluation.

RESULTS

Seven predictors were related to OP by univariate analysis. The serum hCG level on 14th day post-embryo-transfer (hCG₁₄) and 21th day post-embryo-transfer (hCG₂₁) were linear correlated. Therefore, different multivariate regression models were built using hCG₁₄ or hCG₂₁, respectively. After multivariate regression with 5-fold validation, the final indicators in model-1 were age_group, hCG₂₁ and hCG₂₁/hCG₁₄, while age_group, hCG₁₄, and calculated 48-hour-rising-ratio of hCG were the significant predictors in model-2. Model-2 showed better sensitivity and NPV, lower MR, and similar specificity and PPV.

CONCLUSION

This study provided an effective mathematic model for early prediction of OP. The model could be of better clinical significance, especially for clinical counseling to manage patients' stress and anxiety, and for early warning of threatened miscarriage.

Pregnancy of unknown location

Pregnancy of unknown location is a situation in which a positive pregnancy test occurs, but a transvaginal ultrasound does not show intrauterine or ectopic gestation. One great concern of pregnancy of unknown location is that they are cases of ectopic pregnancy whose diagnosis might be postponed. Transvaginal ultrasound is able to identify an ectopic pregnancy with a sensitivity ranging from 87% to 94% and a specificity ranging from 94% to 99%. A patient with pregnancy of unknown location should be followed up until an outcome is obtained. The only valid biomarkers with clinical application and validation are serum levels of the beta fraction of hCG and progesterone. A single serum dosage of hCG is used only to determine whether the value obtained is above or below the discriminatory zone, that means the value of serum hCG above which an intrauterine gestational sac should be visible on ultrasound. Serum progesterone levels are a satisfactory marker of pregnancy viability, but they are unable to predict the location of a pregnancy of unknown location: levels below 5 ng/mL are associated with nonviable gestations, whereas levels above 20 ng/mL are correlated with viable intrauterine pregnancies. Most cases are low risk and can be monitored by expectant management with transvaginal ultrasound and serial serum hCG levels, in addition to the serum progesterone levels. To minimize diagnostic error and intervene during progressive intrauterine gestation, protocol indicates active treatment only in situations when progressive intrauterine pregnancy is excluded and a high possibility of ectopic pregnancy exists.

Development of a novel nomogram for predicting ongoing pregnancy after in vitro fertilization and embryo transfer

Objective

This study aimed to develop a nomogram that predicts ongoing pregnancy after in vitro fertilization and embryo transfer (IVF-ET) using patient age and serum hormonal markers.

Methods

A total of 284 IVF-ET cycles were retrospectively analyzed. At 14 days post-oocyte pick-up (OPU), the serum human chorionic gonadotropin (HCG) and progesterone levels were measured. The main predicted outcome was ongoing pregnancy.

Results

Patient age and serum of HCG and progesterone levels at 14 days post-OPU were good predictors of ongoing pregnancy. The cut-off value and area under the curve (AUC) (95% confidence interval) were 36.5 years and 0.666 (0.599–0.733), respectively, for patient age; 67.8 mIU/mL and 0.969 (0.951–0.987), respectively, for serum HCG level; and 29.8 ng/mL and 0.883 (0.840–0.925), respectively, for serum progesterone level. When the prediction model was constructed using these three parameters, the addition of serum progesterone level to the prediction model did not increase its overall predictability. Furthermore, a high linear co-relationship was found between serum HCG and progesterone levels. Therefore, we developed a new nomogram using patient age and HCG serum level only. The AUC of the newly developed nomogram for predicting ongoing pregnancy after IVF-ET cycles using patient age and serum HCG level was as high as 0.975.

Conclusion

We showed that ongoing pregnancy may be predicted using only patient age and HCG serum level. Our nomogram could help clinicians and patients predict ongoing pregnancy after IVF-ET if the serum JCG level was ≥5 IU/L at 14 days post-OPU.

Serum Human Chorionic Gonadotropin Among Women With and Without Obesity After Single Embryo Transfers

CONTEXT

Serum human chorionic gonadotropin (hCG) levels are essential for diagnosing and monitoring early pregnancy. Obesity is a health care epidemic; however, the performance of this vital serum hormone in women with an elevated body mass index (BMI) is unknown.

OBJECTIVE

To investigate the association of BMI with serum hCG values and rate of hCG increase.

DESIGN

Retrospective cohort study.

SETTING

University-based infertility clinic.

PATIENTS

Women undergoing fresh vs frozen in vitro fertilization cycles with single-day three or five embryo transfers resulting in singleton live births (≥24 weeks' gestational age) from 2008 to 2015.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The initial hCG (mIU/mL, 16 days after oocyte retrieval) and 2-day percentage of hCG increases among BMI categories were compared using multivariable linear and logistic regression, adjusted a priori for the day of embryo transfer.

RESULTS

The initial serum hCG values correlated inversely with the BMI (P < 0.0001, test for trend). Low initial hCG values (<100 mIU/mL) were significantly more common across increasing BMI classes, from 1.4% of normal weight patients to 15.6% of those with a BMI ≥40 kg/m2 (P = 0.001, test for trend). The mean 2-day hCG increases were similar and normal (≥53%) across the BMI groups.

CONCLUSIONS

Patients with obesity achieving live births had statistically significantly lower initial serum hCG values compared with patients who were nonobese. However, the mean 2-day percentage of increases in hCG were similar across BMI categories. The initial hCG values might lack sensitivity for live births in patients with obesity. The rate of hCG increase remains the mainstay of monitoring very early pregnancies after in vitro fertilization. Future studies should investigate whether serum analyte ranges should be adjusted according to the BMI.

Gestational hormone trajectories and early pregnancy failure: a reassessment

BACKGROUND

Studies have commonly assessed the endocrinolgical status of women once miscarriage is threatened or suspected; few studies have explored the antecedent hormonal environment or used a longitudinal strategy. Using refined statistical techniques, we sought to re-evaluate whether gestational hormone trajectories in early pregnancy can identify future miscarriage in asymptomatic pregnancies.

METHODS

This prospective cohort study followed 105 women over-conception; 72 had normal term pregnancy outcomes while 33 experienced early pregnancy failure between 35 and 115 days of gestation. Participants attended a pre-conception and antenatal clinic at Newcastle University, United Kingdom (UK). Evaluation methods included ultrasound, clinical assessments of pregnancy progress and serial measurements of gestational hormones by radioimmunoassays. Linear mixed-effects regression analysis examined hormone relationships with pregnancy outcomes.

RESULTS

Detailed longitudinal illustration of gestational hormones, antecedent to miscarriage indications, revealed early pathophysiological trends. In particular, oestradiol showed as marked a deviation from normal as progesterone before miscarriage was evident, reflecting a deficiency in the ovarian response to rising human chorionic gonadotrophin (hCG) levels. Regression analysis provided equations for gestational hormone slopes that significantly differentiated asymptomatic women with subsequent early pregnancy failure, compared to women with normal term pregnancies. Both progesterone and oestradiol displayed negative mean slopes in pregnancies destined for failure; in this group, both human placental lactogen (hPL) and hCG revealed mean positive trajectories that imitated normal pregnancies but at slower rates of increase.

CONCLUSIONS

Oestradiol, progesterone and hCG trajectories, from 50 days of gestation, have good potential for revealing pathophysiology and for identifying which asymptomatic pregnancies are destined for subsequent failure. In asymptomatic patients where there is concern about viability and ultrasound diagnosis is ambiguous, a combined hormonal profile could contribute to guiding patient care decisions.

Diagnostic protocols for the management of pregnancy of unknown location: a systematic review and meta-analysis

BACKGROUND

There is no international consensus on how to manage women with a pregnancy of unknown location (PUL).

OBJECTIVES

To present a systematic quantitative review summarising the evidence related to management protocols for PUL.

SEARCH STRATEGY

MEDLINE, COCHRANE and DARE databases were searched from 1 January 1984 to 31 January 2017. The primary outcome was accurate risk prediction of women initially diagnosed with a PUL having an ectopic pregnancy (high risk) as opposed to either a failed PUL or intrauterine pregnancy (low risk).

SELECTION CRITERIA

All studies written in the English language, which were not case reports or series that assessed women classified as having a PUL at initial ultrasound.

DATA COLLECTION AND ANALYSIS

Forty-three studies were included. QUADAS-2 criteria were used to assess the risk of bias. We used a novel, linear mixed-effects model and constructed summary receiver operating characteristic curves for the thresholds of interest.

MAIN RESULTS

There was a high risk of differential verification bias in most studies. Meta-analyses of accuracy were performed on (i) single human chorionic gonadotrophin (hCG) cut-off levels, (ii) hCG ratio (hCG at 48 hours/initial hCG), (iii) single progesterone cut-off levels and (iv) the 'M4 model' (a logistic regression model based on the initial hCG and hCG ratio). For predicting an ectopic pregnancy, the areas under the curves (95% CI) for these four management protocols were as follows: (i) 0.42 (0.00-0.99), (ii) 0.69 (0.57-0.78), (iii) 0.69 (0.54-0.81) and (iv) 0.87 (0.83-0.91), respectively.

CONCLUSIONS

The M4 model was the best available method for predicting a final outcome of ectopic pregnancy. Developing and validating risk prediction models may optimise the management of PUL.

TWEETABLE ABSTRACT

Pregnancy of unknown location meta-analysis: M4 model has best test performance to predict ectopic pregnancy.

Endometriosis and Beta-hCG > 775 IU/l Increase the Risk of Non-tube-preserving Surgery for Tubal Pregnancy

Introduction

Tubal pregnancy is the most clinically relevant form of ectopic pregnancy. Surgery consisting of laparoscopic salpingotomy is the therapeutic gold standard. This study looked at risk factors for non-tube-preserving surgery. The aim was to determine a cut-off value for beta-hCG levels, which could be used to predict the extent of tubal surgery.

Materials and Method

97 patients with tubal pregnancy who underwent primary salpingotomy in the Department of Gynecology and Obstetrics of Jena University Hospital between 2010 and 2016 were retrospectively analyzed. A prior medical history of risk factors such as adnexitis, ectopic pregnancy, tubal surgery, treatment for infertility and intrauterine pessary was included in the analysis. The study population was divided into two subgroups: (1) a group which underwent laparoscopic linear salpingotomy, and (2) a group which had laparoscopic partial tubal resection or salpingectomy. Risk factors for salpingectomy were determined using binary logistic regression analysis. Statistical analysis was done using SPSS, version 24.0, to identify risk factors for non-tube-preserving surgery.

Results

68 patients (70.1%) underwent laparoscopic salpingotomy and 29 patients (29.9%) had laparoscopic salpingectomy. The two groups differed with regard to age (p = 0.01) but not with regard to the parameters ‘gestational age’, ‘viability and rupture status of the ectopic pregnancy’ or ‘symptoms at presentation’. Patients who were known to have endometriosis prior to surgery or who were diagnosed with endometriosis intraoperatively were more likely to undergo salpingectomy (OR: 3.28; 95% CI: 0.9 – 10.8; p = 0.05). Calculated mean beta-hCG levels were higher in the salpingectomy group compared to the group who had tube-preserving salpingotomy (3277.8 IU/l vs. 9338.3 IU/l, p = 0.01). A cut-off beta-hCG value of 775 IU/l prior to surgery was predictive for salpingectomy with a true positive rate of 86.2% and increased the probability that salpingectomy would be necessary (OR: 5.23; 95% CI: 0.229 – 0.471; p = 0.005).

Conclusion

Endometriosis and a beta-hCG value of more than 775 IU/l significantly increased the risk for non-tube-preserving surgery in women with tubal pregnancy.

Trends in the Management of Nonviable Pregnancies of Unknown Location in the United States

BACKGROUND

When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL.

METHODS

A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States.

RESULTS

A total of 214 physicians responded. When presented with a PUL by ultrasound and a βhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional βhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial βhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians.

CONCLUSIONS

Based on our findings, there does not appear to be a consensus regarding the management of a PUL.

Gestational Tubal Choriocarcinoma Presenting as a Pregnancy of Unknown Location following Ovarian Induction

The management of pregnancy of unknown location (PUL) can be a challenging situation, since it can present as several different conditions. Here we describe a rare case of gestational choriocarcinoma arising in the fallopian tube after ovarian induction in an infertile patient. The patient received clomiphene for ovarian induction and had rising levels of human chorionic gonadotropin (hCG) over nine months without sign of pregnancy. After referral to our center, the patient was diagnosed with a paraovarian tumor, which revealed a gestational choriocarcinoma arising in the fallopian tube; the final diagnosis was supported by pathological and cytogenomic analysis. Malignancies, such as gestational trophoblastic disease, should be in the differential diagnosis of PUL; the early recognition of these conditions is key for the proper treatment and favorable outcome.

Factors to consider in pregnancy of unknown location

The management of women with a pregnancy of unknown location (PUL) can vary significantly and often lacks a clear evidence base. Intensive follow-up is usually required for women with a final outcome of an ectopic pregnancy. This, however, only accounts for a small proportion of women with a pregnancy of unknown PUL location. There remains a clear clinical need to rationalize the follow-up of PUL so women at high risk of having a final outcome of an ectopic pregnancy are followed up more intensively and those PUL at low risk of having an ectopic pregnancy have their follow-up streamlined. This review covers the main management strategies published in the current literature and aims to give clinicians an overview of the most up-to-date evidence that they can take away into their everyday clinical practice when caring for women with a PUL.

Serum human chorionic gonadotropin measured 7 days following day 3 embryo transfer might predict pregnancy outcome in IVF

This prospective study investigated the predictive value of pregnancy outcomes with serum human chorionic gonadotropin (hCG) 7 days after day 3 embryo transfer (D3 ET), and whether estradiol (E2) and progesterone (P) improved the diagnostic efficiency. The study comprised 280 in vitro fertilization and embryo transfer (IVF-ET) cycles. Serum samples were obtained 7 days after D3 ET to measure hCG, E2, and P concentrations. Statistical analyses were conducted to evaluate the predictive value for pregnancy outcomes. We found significant differences in hCG level between pregnancy and non-pregnancy, viable and non-viable pregnancy, biochemical and viable pregnancy, as well as singleton and multiple pregnancy. An hCG cutoff value of 2.5 mIU/mL is predictive of pregnancy with a positive predictive value (PPV) of 95.9% and a negative predictive value (NPV) of 92.4%. An hCG value of 10.8 mIU/mL is predictive of a multiple pregnancy with an NPV of 98.1%. The area under the hCG curve between pregnancy and non-pregnancy was not improved by adding E2, P, or combined E2/P. Our results suggest a predictive value of pregnancy outcome with serum hCG drawn 7 days after D3 ET in IVF, and the diagnostic accuracy is not improved by adding measurements of E2/P.

The Diagnosis and Treatment of Ectopic Pregnancy

BACKGROUND

Extrauterine pregnancy is a complication of the first trimester of pregnancy that arises in 1.3-2.4% of all pregnancies.

METHODS

This review is based on articles and guidelines retrieved by a selective PubMed search.

RESULTS

The presentation of extrauterine pregnancy is highly variable, ranging from an asymptomatic state, to pelvic pain that is worse on one side, to tubal rupture with hemorrhagic shock. 75% of tubal pre gnancies can be detected by transvaginal ultrasonography. In patients with a vital extrauterine pregnancy, the human chorionic gonadotropin concentration generally doubles within 48 hours. Laparoscopy is the gold standard of treatment. Two randomized, controlled trials comparing organ-preserving treatment with ablative surgery revealed no significant difference in pregnancy rates after the intervention, but precise details of the surgical procedures were not provided, and long-term fertility data are lacking. Metho - trexate therapy should be used only for strict indications.

CONCLUSION

Further randomized, controlled trials with longer follow-up will be needed to answer currently open questions about the potential for individualized surgical treatment and the proper role of pharmacotherapy.

Association between three-dimensional transvaginal sonographic markers and outcome of pregnancy of unknown location: a pilot study

OBJECTIVE

To assess the accuracy of three-dimensional (3D) transvaginal sonographic (TVS) parameters in predicting the evolution of a pregnancy of unknown location (PUL).

METHODS

This was a prospective observational study performed at the early pregnancy unit of a university hospital from September 2008 to June 2012. Women with a positive pregnancy test without any signs of intra- or extrauterine pregnancy at their first TVS examination were considered eligible and a 3D dataset containing the entire uterus was acquired. An experienced observer analyzed all 3D datasets for assessment of the following parameters: endometrial thickness, volume, mean gray-scale index and asymmetry. Women were followed until they were classified as having: (i) non-visualized pregnancy loss (NVPL); (ii) intrauterine pregnancy (IUP); or (iii) ectopic pregnancy or persistent PUL. We compared the values of the TVS parameters across the three groups. We also assessed the area under the receiver-operating characteristics curve of the 3D-TVS parameters in comparison to that for serum β-human chorionic gonadotropin (β-hCG) ratio (48 h/baseline) to predict PUL outcome. We then evaluated whether combining the 3D-TVS parameters with serum β-hCG ratio improved the predictive accuracy for PUL outcome by performing a logistic regression analysis.

RESULTS

During the study period 4939 consecutive pregnant women presented at the unit for their initial TVS examination and 325 (7%) were classified as having a PUL, of whom 161 women were enrolled and had a 3D scan of the uterus. However, 19 were excluded because of incomplete follow-up. Data from 142 women with PUL were therefore included in the analysis and the outcomes of these women were: NVPL in 98 (69%), IUP in 27 (19%) and ectopic pregnancy + persistent PUL in 14 + 3 = 17 (12%). Endometrial thickness, endometrial volume and the proportion of women with asymmetric endometrial shape differed significantly between the outcome groups. Endometrial thickness and volume could be used as reasonable predictors of both NVPL and IUP, whereas asymmetric endometrial shape and mean gray-scale index could be used as reasonable predictors of IUP only. The best single parameter to predict PUL outcomes was the β-hCG ratio. Regression analysis demonstrated that endometrial volume and endometrial shape asymmetry added significantly to the β-hCG ratio in predicting IUP but not NVPL.

CONCLUSIONS

3D-TVS markers have a low diagnostic accuracy in predicting PUL outcome. The addition of endometrial volume and shape asymmetry improves the accuracy of the β-hCG ratio in predicting IUP. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Managing pregnancy of unknown location based on initial serum progesterone and serial serum hCG levels: development and validation of a two-step triage protocol

OBJECTIVES

A uniform rationalized management protocol for pregnancies of unknown location (PUL) is lacking. We developed a two-step triage protocol to select PUL at high risk of ectopic pregnancy (EP), based on serum progesterone level at presentation (step 1) and the serum human chorionic gonadotropin (hCG) ratio, defined as the ratio of hCG at 48 h to hCG at presentation (step 2).

METHODS

This was a cohort study of 2753 PUL (301 EP), involving a secondary analysis of prospectively and consecutively collected PUL data from two London-based university teaching hospitals. Using a chronological split we used 1449 PUL for development and 1304 for validation. We aimed to assign PUL as low risk with high confidence (high negative predictive value (NPV)) while classifying most EP as high risk (high sensitivity). The first triage step assigned PUL as low risk using a threshold of serum progesterone at presentation. The remaining PUL were triaged using a novel logistic regression risk model based on hCG ratio and initial serum progesterone (second step), defining low risk as an estimated EP risk of < 5%.

RESULTS

On validation, initial serum progesterone ≤ 2 nmol/L (step 1) classified 16.1% PUL as low risk. Second-step classification with the risk model selected an additional 46.0% of all PUL as low risk. Overall, the two-step protocol classified 62.1% of PUL as low risk, with an NPV of 98.6% and a sensitivity of 92.0%. When the risk model was used in isolation (i.e. without the first step), 60.5% of PUL were classified as low risk with 99.1% NPV and 94.9% sensitivity.

CONCLUSION

PUL can be classified efficiently into being either high or low risk for complications using a two-step protocol involving initial progesterone and hCG levels and the hCG ratio. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

The clinical performance of the M4 decision support model to triage women with a pregnancy of unknown location as at low or high risk of complications

STUDY QUESTION

What are the adverse outcomes associated with using the M4 model in everyday clinical practice for women with pregnancy of unknown location (PUL)?

SUMMARY ANSWER

There were 17/835 (2.0%) adverse events and no serious adverse events associated with the performance of the M4 model in clinical practice.

WHAT IS KNOWN ALREADY

The M4 model has previously been shown to stratify women classified as a PUL as at low or high risk of complications with a good level of test performance. The triage performance of the M4 model is better than single measurements of serum progesterone or the hCG ratio (serum hCG at 48 h/hCG at presentation).

STUDY DESIGN, SIZE, DURATION

A prospective multi-centre cohort study of 1022 women with a PUL carried out between August 2012 and December 2013 across 2 university teaching hospitals and 1 district general hospital.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women presenting with a PUL to the early pregnancy units of the three hospitals were recruited. The final outcome for PUL was either a failed PUL (FPUL), intrauterine pregnancy (IUP) or ectopic pregnancy (EP) (including persistent PUL (PPUL)), with EP and PPUL considered high-risk PUL. Their hCG results at 0 and 48 h were entered into the M4 model algorithm. If the risk of EP was ≥5%, the PUL was predicted to be high-risk and the participant was asked to re-attend 48 h later for a repeat hCG and transvaginal ultrasound scan by a senior clinician. If the PUL was classified as 'low risk, likely failed PUL', the participant was asked to perform a urinary pregnancy test 2 weeks later. If the PUL was classified as 'low risk, likely intrauterine', the participant was scheduled for a repeat scan in 1 week. Deviations from the management protocol were recorded as either an 'unscheduled visit (participant reason)', 'unscheduled visit (clinician reason)' or 'differences in timing (blood test/ultrasound)'. Adverse events were assessed using definitions outlined in the UK Good Clinical Practice Guidelines' document.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 835 (82%) women classified as a PUL were managed according to the M4 model (9 met the exclusion criteria, 69 were lost to follow-up, 109 had no hCG result at 48 h). Of these, 443 (53%) had a final outcome of FPUL, 298 (36%) an IUP and 94 (11%) an EP. The M4 model predicted 70% (585/835) PUL as low risk, of which 568 (97%) were confirmed as FPUL or IUP. Of the 17 EP and PPUL misclassified as low risk, 5 had expectant management, 7 medical management with methotrexate and 5 surgical intervention.Nineteen PUL had an unscheduled visit (participant reason), 38 PUL had an unscheduled visit (clinician reason) and 68 PUL had deviations from protocol due to a difference in timing (blood test/ultrasound).Adverse events were reported in 26 PUL and 1 participant had a serious adverse event. A total of 17/26 (65%) adverse events were misclassifications of a high risk PUL as low risk by the M4 model, while 5/26 (19%) adverse events were related to incorrect clinical decisions. Four of the 26 adverse events (15%) were secondary to unscheduled admissions for pain/bleeding. The serious adverse event was due to an incorrect clinical decision.

LIMITATIONS, REASONS FOR CAUTION

A limitation of the study was that 69/1022 (7%) of PUL were lost to follow-up. A 48 h hCG level was missing for 109/1022 (11%) participants.

WIDER IMPLICATIONS OF THE FINDINGS

The low number of adverse events (2.0%) suggests that expectant management of PUL using the M4 prediction model is safe. The model is an effective way of triaging women with a PUL as being at high- and low-risk of complications and rationalizing follow-up. The multi-centre design of the study is more likely to make the performance of the M4 model generalizable in other populations.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

Not applicable.

Ultrasound imaging in the management of bleeding and pain in early pregnancy

Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.

Time to revisit the human chorionic gonadotropin discriminatory level in the management of pregnancy of unknown location

OBJECTIVES

The purpose of this study was to review the management and outcomes of all patients with pregnancy of unknown location who had serum human chorionic gonadotropin (hCG) levels greater than 1000 mIU/mL in our institution and to determine the likelihood of a subsequent normal intrauterine pregnancy at different hCG discriminatory levels.

METHODS

A retrospective review was performed on all women admitted with the diagnosis of pregnancy of unknown location and an hCG level greater than 1000 mIU/mL over a 5-year period (July 2007 to June 2012). Patients were identified from a computerized hCG result database. The medical records, including sonographic findings, hCG levels, and outcomes, were reviewed.

RESULTS

A total of 113 patients were identified. There were 23 viable intrauterine pregnancies (20.4%) and 22 visualized ectopic pregnancies (19.5%). The highest hCG level associated with a subsequent normal intrauterine pregnancy was 9083 mIU/mL in a patient with triplet pregnancy. Possible factors associated with nonvisualization of a normal intrauterine pregnancy included uterine fibroids, adenomyosis, endometrial polyps, and obesity. The negative laparoscopy rate was 48.8%.

CONCLUSIONS

Viable intrauterine pregnancy is possible in patients with pregnancy of unknown location and hCG levels above the generally accepted discriminatory zone, strict adherence to which can potentially disrupt a normal pregnancy. We support the need for judicious use of the hCG discriminatory level in hemodynamically stable patients with pregnancy of unknown location, and the decision to intervene should not be based solely on a single hCG level.

Ectopic pregnancy prediction in women with a pregnancy of unknown location: data beyond 48 h are necessary

STUDY QUESTION

Are there improvements in the accuracy of prediction of ectopic pregnancy (EP) in women with early symptomatic pregnancy using human chorionic gonadotrophin (hCG) curves when clinicians consider visits beyond the first 48 h after initial presentation?

SUMMARY ANSWER

Two hCG values, measured 48 h (2 days) apart, are often not sufficient to accurately predict the outcome of a woman with a pregnancy of unknown location (PUL), but adding a third visit on Day 4 or 7 significantly improved the prediction for 1 in 15 women.

WHAT IS KNOWN ALREADY

The use of serial hCG values is commonly used to aid in the prediction of the final diagnosis in women with a PUL. Initial outcome predictions based on two hCG values may often be incorrect.

STUDY DESIGN, SIZE, DURATION

This retrospective multicenter cohort study included 646 women with a PUL, recruited over 2 years. Of these women, 146 were ultimately diagnosed with EP.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women presenting to the emergency room with first trimester pain or bleeding, with a PUL, at least 2 hCG values and a definitive final diagnosis from the University of Pennsylvania, University of Miami and University of Southern California, were recruited from 2007 to 2009.

MAIN RESULTS AND THE ROLE OF CHANCE

Using currently recommended prediction rules, adding a third hCG evaluation on Day 4 after initial presentation significantly improved the accuracy of initial prediction from the first two values (48 h apart, or Day 2) by 9.3% (P = 0.015). Adding a third value on Day 7 improved prediction significantly by 6.7% (P = 0.031), compared with prediction based on first two values. The improvement in prediction by assessing four hCG values (Days 0, 2, 4 and 7) compared with three values (Days 0, 2 and 4) was 1.3% and not statistically significant.

LIMITATIONS, REASONS FOR CAUTION

Missing data imputation likely biased results toward the null; predicted outcomes may not match those made by clinicians; and the study does not predict intrauterine pregnancy and spontaneous miscarriage separately.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides useful information for the prediction of outcomes for women with a symptomatic first trimester pregnancy of unknown location, but may not be generalizable to all pregnant women.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by NIH grant numbers R01-HD036455 to Dr Barnhart and Dr Sammel, K24HD060687 to Dr Barnhart, and 5T32MH065218 to Ms. Zee. The authors have no conflicts of interest to declare.

Pregnancy of unknown location

Pregnancy of unknown location (PUL) is defined as the situation when the pregnancy test is positive but there are no signs of intrauterine pregnancy or an extrauterine pregnancy via transvaginal ultra-sonography. It is not always possible to determine the location of the pregnancy in cases of PUL. The reported rate of PUL among women attending early pregnancy units varies between 5 and 42% in the literature and the frequency of PUL incidents has increased with the increase in the number of early pregnancy units. The management of PUL seems to be highly crucial in obstetrics clinics. Therefore, in the current review, issues identified from the literature related to pregnancy of unknown location, potential tools for prediction and algorithms will be discussed.

Ectopic pregnancy: how the diagnostic and therapeutic management has changed

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