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Hill CJ, Phelan MM, Dutton PJ, Busuulwa P, Maclean A, Davison AS, Drury JA, Tempest N, Horne AW, Gutiérrez EC, Hapangama DK. Diagnostic utility of clinicodemographic, biochemical and metabolite variables to identify viable pregnancies in a symptomatic cohort during early gestation. Sci Rep 2024; 14:11172. [PMID: 38750192 PMCID: PMC11096363 DOI: 10.1038/s41598-024-61690-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
A significant number of pregnancies are lost in the first trimester and 1-2% are ectopic pregnancies (EPs). Early pregnancy loss in general can cause significant morbidity with bleeding or infection, while EPs are the leading cause of maternal mortality in the first trimester. Symptoms of pregnancy loss and EP are very similar (including pain and bleeding); however, these symptoms are also common in live normally sited pregnancies (LNSP). To date, no biomarkers have been identified to differentiate LNSP from pregnancies that will not progress beyond early gestation (non-viable or EPs), defined together as combined adverse outcomes (CAO). In this study, we present a novel machine learning pipeline to create prediction models that identify a composite biomarker to differentiate LNSP from CAO in symptomatic women. This prospective cohort study included 370 participants. A single blood sample was prospectively collected from participants on first emergency presentation prior to final clinical diagnosis of pregnancy outcome: LNSP, miscarriage, pregnancy of unknown location (PUL) or tubal EP (tEP). Miscarriage, PUL and tEP were grouped together into a CAO group. Human chorionic gonadotrophin β (β-hCG) and progesterone concentrations were measured in plasma. Serum samples were subjected to untargeted metabolomic profiling. The cohort was randomly split into train and validation data sets, with the train data set subjected to variable selection. Nine metabolite signals were identified as key discriminators of LNSP versus CAO. Random forest models were constructed using stable metabolite signals alone, or in combination with plasma hormone concentrations and demographic data. When comparing LNSP with CAO, a model with stable metabolite signals only demonstrated a modest predictive accuracy (0.68), which was comparable to a model of β-hCG and progesterone (0.71). The best model for LNSP prediction comprised stable metabolite signals and hormone concentrations (accuracy = 0.79). In conclusion, serum metabolite levels and biochemical markers from a single blood sample possess modest predictive utility in differentiating LNSP from CAO pregnancies upon first presentation, which is improved by variable selection and combination using machine learning. A diagnostic test to confirm LNSP and thus exclude pregnancies affecting maternal morbidity and potentially life-threatening outcomes would be invaluable in emergency situations.
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Affiliation(s)
- Christopher J Hill
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - Marie M Phelan
- High Field NMR Facility, Liverpool Shared Research Facilities, University of Liverpool, Liverpool, L69 7TX, UK
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Philip J Dutton
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
- Liverpool Women's Hospital NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - Paula Busuulwa
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
- Liverpool Women's Hospital NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - Alison Maclean
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - Andrew S Davison
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8SP, UK
| | - Josephine A Drury
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - Nicola Tempest
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
- Liverpool Women's Hospital NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK
| | - Andrew W Horne
- Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, EH16 4UU, UK
| | - Eva Caamaño Gutiérrez
- High Field NMR Facility, Liverpool Shared Research Facilities, University of Liverpool, Liverpool, L69 7TX, UK
- Computational Biology Facility, Liverpool Shared Research Facilities, University of Liverpool, Liverpool, L69 7ZB, UK
| | - Dharani K Hapangama
- Department of Women's and Children's Health, Centre for Women's Health Research, Institute of Life Course and Medical Sciences, University of Liverpool, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK.
- Liverpool Women's Hospital NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, L8 7SS, UK.
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Kyriacou C, Ledger A, Bobdiwala S, Ayim F, Kirk E, Abughazza O, Guha S, Vathanan V, Gould D, Timmerman D, Van Calster B, Bourne T. Updating M6 pregnancy of unknown location risk-prediction model including evaluation of clinical factors. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:408-418. [PMID: 37842861 DOI: 10.1002/uog.27515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/19/2023] [Accepted: 10/05/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Ectopic pregnancy (EP) is a major high-risk outcome following a pregnancy of unknown location (PUL) classification. Biochemical markers are used to triage PUL as high vs low risk to guide appropriate follow-up. The M6 model is currently the best risk-prediction model. We aimed to update the M6 model and evaluate whether performance can be improved by including clinical factors. METHODS This prospective cohort study recruited consecutive PUL between January 2015 and January 2017 at eight units (Phase 1), with two centers continuing recruitment between January 2017 and March 2021 (Phase 2). Serum samples were collected routinely and sent for β-human chorionic gonadotropin (β-hCG) and progesterone measurement. Clinical factors recorded were maternal age, pain score, bleeding score and history of EP. Based on transvaginal ultrasonography and/or biochemical confirmation during follow-up, PUL were classified subsequently as failed PUL (FPUL), intrauterine pregnancy (IUP) or EP (including persistent PUL (PPUL)). The M6 models with (M6P ) and without (M6NP ) progesterone were refitted and extended with clinical factors. Model validation was performed using internal-external cross-validation (IECV) (Phase 1) and temporal external validation (EV) (Phase 2). Missing values were handled using multiple imputation. RESULTS Overall, 5473 PUL were recruited over both phases. A total of 709 PUL were excluded because maternal age was < 16 years or initial β-hCG was ≤ 25 IU/L, leaving 4764 (87%) PUL for analysis (2894 in Phase 1 and 1870 in Phase 2). For the refitted M6P model, the area under the receiver-operating-characteristics curve (AUC) for EP/PPUL vs IUP/FPUL was 0.89 for IECV and 0.84-0.88 for EV, with respective sensitivities of 94% and 92-93%. For the refitted M6NP model, the AUCs were 0.85 for IECV and 0.82-0.86 for EV, with respective sensitivities of 92% and 93-94%. Calibration performance was good overall, but with heterogeneity between centers. Net Benefit confirmed clinical utility. The change in AUC when M6P was extended to include maternal age, bleeding score and history of EP was between -0.02 and 0.01, depending on center and phase. The corresponding change in AUC when M6NP was extended was between -0.01 and 0.03. At the 5% threshold to define high risk of EP/PPUL, extending M6P altered sensitivity by -0.02 to -0.01, specificity by 0.03 to 0.04 and Net Benefit by -0.005 to 0.006. Extending M6NP altered sensitivity by -0.03 to -0.01, specificity by 0.05 to 0.07 and Net Benefit by -0.005 to 0.006. CONCLUSIONS The updated M6 model offers accurate diagnostic performance, with excellent sensitivity for EP. Adding clinical factors to the model improved performance in some centers, especially when progesterone levels were not suitable or unavailable. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Kyriacou
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - A Ledger
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - S Bobdiwala
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - F Ayim
- Department of Gynaecology, Hillingdon Hospital NHS Trust, London, UK
| | - E Kirk
- Department of Gynaecology, Royal Free NHS Foundation Trust, London, UK
| | - O Abughazza
- Department of Gynaecology, Royal Surrey County Hospital, Guildford, UK
| | - S Guha
- Department of Gynaecology, Chelsea and Westminster NHS Trust, London, UK
| | - V Vathanan
- Department of Gynaecology, Wexham Park Hospital, London, UK
| | - D Gould
- Department of Gynaecology, St Mary's Hospital, London, UK
| | - D Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Gynecology, University Hospital Leuven, Leuven, Belgium
| | - B Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - T Bourne
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Gynecology, University Hospital Leuven, Leuven, Belgium
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Moses AS, Kadam L, St Lorenz A, Baldwin MK, Morgan T, Hebert J, Park Y, Lee H, Demessie AA, Korzun T, Mamnoon B, Alani AWG, Taratula O, Myatt L, Taratula OR. Nano-Theranostic Modality for Visualization of the Placenta and Photo-Hyperthermia for Potential Management of Ectopic Pregnancy. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2023; 19:e2202343. [PMID: 36394151 PMCID: PMC9839489 DOI: 10.1002/smll.202202343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/26/2022] [Indexed: 05/03/2023]
Abstract
Ectopic pregnancy (EP) is the leading cause of maternity-related death in the first trimester of pregnancy. Approximately 98% of ectopic implantations occur in the fallopian tube, and expedient management is crucial for preventing hemorrhage and maternal death in the event of tubal rupture. Current ultrasound strategies misdiagnose EP in up to 40% of cases, and the failure rate of methotrexate treatment for confirmed EP exceeds 10%. Here the first theranostic strategy for potential management of EP is reported using a near-infrared naphthalocyanine dye encapsulated within polymeric nanoparticles. These nanoparticles preferentially accumulate in the developing murine placenta within 24 h following systemic administration, and enable visualization of implantation sites at various gestational stages via fluorescence and photoacoustic imaging. These nanoparticles do not traverse the placental barrier to the fetus or impact fetal development. However, excitation of nanoparticles localized in specific placentas with focused NIR light generates heat (>43 °C) sufficient for disruption of placental function, resulting in the demise of targeted fetuses with no effect on adjacent fetuses. This novel approach would enable diagnostic confirmation of EP when current imaging strategies are unsuccessful, and elimination of EP could subsequently be achieved using the same nano-agent to generate localized hyperthermia resulting in targeted placental impairment.
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Affiliation(s)
- Abraham S Moses
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Leena Kadam
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anna St Lorenz
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Maureen K Baldwin
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Terry Morgan
- Department of Pathology and Laboratory Medicine, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Jessica Hebert
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Youngrong Park
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Hyelim Lee
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Ananiya A Demessie
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Tetiana Korzun
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Babak Mamnoon
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Adam W G Alani
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Oleh Taratula
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Olena R Taratula
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
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Lentscher JA, Colburn ZT, Ortogero N, Gillette L, Leonard GT, Burney RO, Chow GE. An intrauterine genomic classifier reliably delineates the location of nonviable pregnancies. Fertil Steril 2021; 116:138-146. [PMID: 33771330 DOI: 10.1016/j.fertnstert.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare the intrauterine gene expression signatures of women with surgically confirmed ectopic pregnancy (ECT) and those of women with miscarriage to inform the development of a genomic classifier for the reliable delineation of pregnancy location in women with clinically nonviable pregnancies of unknown location (NV-PULs). DESIGN Discovery-based prospective cohort study. SETTING Academic medical center. PATIENT(S) Women with clinically nonviable early pregnancy to include abnormal intrauterine pregnancy (AIUP), ECT, or NV-PUL. INTERVENTION(S) Endometrial (EM) pipelle sampling of the uterus was conducted at the time of scheduled surgery for clinically nonviable early pregnancy (dilation and curettage, manual vacuum aspiration, or laparoscopy). All pregnancy locations were surgically and/or histologically confirmed as intrauterine or ectopic. MAIN OUTCOME MEASURE(S) Gene expression profiles as determined by array hybridization, quantitative real-time polymerase chain reaction, and nCounter technology. RESULT(S) Intrauterine samples were obtained by EM pipelle from 27 women undergoing surgery for a clinically nonviable early pregnancy. Comparison of array-based global gene expression signatures from women with histologically confirmed ECT versus AIUP revealed 61 differentially expressed genes from which the 5 most informative were included in the pregnancy location classifier. All 5 genes (C20orf85, LRRC46, RSPH4A, WDR49, and ZBBX) were cilia-associated and showed increased expression in pipelle samples from women with ECT relative to expression in samples from women with AIUP. The 5-gene classifier demonstrated an average area under the receiver operator characteristic curve of 0.97 for the detection of ECT. In an external test set composed of publicly available EM pipelle-based gene expression data from a study with similar ECT and AIUP cohorts (n = 19), the classifier revealed an average area under the receiver operator characteristic curve of 0.84. CONCLUSION(S) Consistently increased expression of cilia-associated genes in the uterine cavity of women with ECT provides a reliable molecular signal for the delineation of pregnancy location in women with clinically assessed NV-PUL. A classifier consisting of the 5 most informative cilia-associated genes demonstrated 91% (42/46) accuracy in predicting the pregnancy location.
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Affiliation(s)
- Jessica A Lentscher
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington.
| | - Zachary T Colburn
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Nicole Ortogero
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Laurel Gillette
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - George T Leonard
- Department of Pathology, Madigan Army Medical Center, Tacoma, Washington
| | - Richard O Burney
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington; Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Gregory E Chow
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington
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Thang NM, Thi Huyen Anh N, Hai Thanh P. Rectal ectopic pregnancy: A case report. Medicine (Baltimore) 2021; 100:e24626. [PMID: 33578575 PMCID: PMC7886477 DOI: 10.1097/md.0000000000024626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/03/2021] [Accepted: 01/14/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Abdominal ectopic pregnancy is a very rare form of ectopic pregnancy, yet is associated with higher morbidity due to atypical clinical presentation and misdiagnosis. In this report, we present a case of abdominal ectopic pregnancy with placenta invading to the rectal wall. PATIENT CONCERNS A 32-year-old woman was admitted to our hospital with an increasing serum ß-hCG level after diagnostic laparoscopy for ectopic pregnancy in the provincial hospital. During the laparoscopy, no gestational sac was found. She was discharged and scheduled for a follow-up visit to assess the level of ß-hCG. One week later, her serum ß-hCG level increased from 7000 IU/l to 12000 IU/l. Transvaginal Doppler ultrasound and abdominal computed tomography (CT) angiography demonstrated a right adnexal mass adherent to the rectal wall. DIAGNOSIS A rectal ectopic pregnancy is suspected. INTERVENTIONS Laparoscopic surgery was successfully performed in our hospital to remove the products of conception. OUTCOMES Histologic examination confirmed the diagnosis of a rectal ectopic pregnancy. The patient had an uneventful recovery and was discharged the next few days. LESSONS This case report reveals that an abdominal pregnancy is remarkably difficult to diagnose and manage. The gynecologists need to be aware of the possibility of gestational sac between the uterus and the rectum. To make early diagnosis of abdominal pregnancy, they need to combine clinical findings, imaging techniques (ultrasound, CT, MRI) and serial human chorionic gonadotropin measurements. Laparoscopic management should be considered in early abdominal pregnancy. A multidisciplinary team of gynecologists and gastrointestinal surgeons is required to deal with rectal ectopic pregnancy.
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Affiliation(s)
- Nguyen Manh Thang
- Department of Obstetrics and Gynecology, Hanoi Medical University
- National Hospital of Obstetrics and Gynecology
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Zhang N, Yang L, Wang Y, Li X, Zhang C, Xu J. Primary hepatic ectopic pregnancy in a patient with polycystic ovary syndrome: A case report. Medicine (Baltimore) 2020; 99:e19649. [PMID: 32221090 PMCID: PMC7220081 DOI: 10.1097/md.0000000000019649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Hepatic ectopic pregnancy is an extremely rare ectopic pregnancy. This study aimed to report a case of primary hepatic pregnancy in a patient with polycystic syndrome. PATIENT CONCERNS A 30-year-old woman presented with vaginal bleeding after 63 days of amenorrhea. DIAGNOSIS The patient was initially diagnosed with liver ectopic pregnancy using abdominal ultrasound and abdominal computed tomography (CT). INTERVENTIONS The patient underwent laparoscopic exploration to reconfirm the gestational sac in the liver and abdominal surgery to remove liver gestation. The postoperative review of abdominal CT and the level of serum human chorionic gonadotropin (hCG) was performed. OUTCOMES The postoperative pathological examination revealed a fluffy tissue in the liver tissue and a blood clot. The patient's vital signs were normal, and she was advised regular follow-up after discharge from the hospital. One month later, the serum hCG level reduced to 0.32 mIU/mL (reference range 0-5 mIU/mL). LESSONS If the level of beta-human chorionic gonadotropin (β-HCG) is higher than normal in women of childbearing age and no gestational sac is found in the uterine cavity, the location of pregnancy and gestational sac should be positively confirmed. Also, the possibility of ectopic pregnancy in the abdominal cavity should be considered, and the relevant imaging and biochemical examinations should be improved to avoid delay in diagnosis and treatment.
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Affiliation(s)
- Ning Zhang
- School of Clinical Medicine, Jining Medical University
| | | | | | - Xiaoyu Li
- Department of Otolaryngology-Head and Neck Surgery, The Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
| | - Chao Zhang
- School of Clinical Medicine, Jining Medical University
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Chen L, Liu J, Shu J, Zeng W, Zhao X. Successful laparoscopic management of diaphragmatic pregnancy:a rare case report and brief review of literature. BMC Pregnancy Childbirth 2019; 19:99. [PMID: 30922250 PMCID: PMC6438013 DOI: 10.1186/s12884-019-2248-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/18/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Abdominal ectopic pregnancies are rare category of ectopic pregnancies.We describe a ectopic pregnancy implanted on the surface of diaphragm and highlight the difficult clinical course of an abdominal ectopic pregnancy managed with strategic procedural intervention. CASE PRESENTATION A 33-year-old Chinese woman with abdominal pain was diagnosed with ectopic pregnancy implanted in the liver according to CT and advised to transfer the patient to tertiary referral center. The patient had a significant increasing abdominal pain and intense reflex sensitivity in the right shoulder when she presented to our hospital. Laparoscopic surgery was decided immediately with the impression of ruptured abdominal pregnancy and hemorrhagic shock. It was found that ectopic pregnancy was implanted on the diaphragmatic surface.The pregnant tissue was completely resected from the diaphragm and bipolar electrocoagulation was used to control bleeding. The patient was stable and discharged 3 days after surgery in a good condition. CONCLUSION CT or MRI should be considered as an alternative to TVS in the management of ectopic pregnancy patients with unusual presentations. A thorough observation of the entire pelvis and upper abdomen during laparoscopic exploration is crucial for diagnosis.
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Affiliation(s)
- Lifeng Chen
- Departments of Gynecology, Zhejiang Provincial People’s Hospital, People’s Hospital Of Hangzhou Medical College, No. 158 Shangtang Rd, Hangzhou, 310014 People’s Republic of China
| | - Jinwei Liu
- Departments of Gynecology, Zhejiang Provincial People’s Hospital, People’s Hospital Of Hangzhou Medical College, No. 158 Shangtang Rd, Hangzhou, 310014 People’s Republic of China
| | - Jing Shu
- Departments of Gynecology, Zhejiang Provincial People’s Hospital, People’s Hospital Of Hangzhou Medical College, No. 158 Shangtang Rd, Hangzhou, 310014 People’s Republic of China
| | - Wenjie Zeng
- Departments of Gynecology, Zhejiang Provincial People’s Hospital, People’s Hospital Of Hangzhou Medical College, No. 158 Shangtang Rd, Hangzhou, 310014 People’s Republic of China
| | - Xiaofeng Zhao
- Departments of Gynecology, Zhejiang Provincial People’s Hospital, People’s Hospital Of Hangzhou Medical College, No. 158 Shangtang Rd, Hangzhou, 310014 People’s Republic of China
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Memtsa M, Jurkovic D, Jauniaux ERM. Diagnostic Biomarkers for Predicting Adverse Early Pregnancy Outcomes. BJOG 2018; 126:e107-e113. [DOI: 10.1111/1471-0528.15468] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hastie R, Lim E, Sluka P, Campbell L, Horne AW, Ellett L, Hannan NJ, Brownfoot F, Kaitu'u-Lino TJ, Tong S. Vinorelbine Potently Induces Placental Cell Death, Does Not Harm Fertility and is a Potential Treatment for Ectopic Pregnancy. EBioMedicine 2018; 29:166-176. [PMID: 29429891 PMCID: PMC5925452 DOI: 10.1016/j.ebiom.2018.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/15/2018] [Accepted: 01/31/2018] [Indexed: 11/30/2022] Open
Abstract
Ectopic pregnancies complicate 1–2 pregnancies and are a leading cause of maternal death. An effective oral drug therapy that replaces surgery might make its treatment safer, cheaper, simpler and therefore more widely accessible. The only current medical treatment offered to women is intramuscular methotrexate, but this only reliably resolves smaller ectopic pregnancies. As such, many ectopic pregnancies require surgical excision. We show that vinorelbine, an orally available chemotherapeutic agent, potently induced placental cell death but did not harm fertility in mice. Vinorelbine was 100–1000 times more potent than methotrexate in inducing placental cell death in vitro, and more potent than combination methotrexate and gefitinib (another proposed treatment for ectopic pregnancy being evaluated in phase III trials). Mechanistically, it caused microtubule condensation, blocked mitosis and activated the apoptosis cascade in placental cells. Vinorelbine was more efficacious than methotrexate ± gefitinib in reducing the volume of placental cell tumors xenografted subcutaneously in SCID mice. Mice exposed to vinorelbine and allowed to breed, following a four week washout period, displayed normal fertility, however long-term fertility was not assessed. Human Fallopian tubes treated with vinorelbine did not exhibit up-regulation of apoptosis molecules. Our findings show that placental cells appear sensitive to vinorelbine and it has potential as a tablet-only approach to treat ectopic pregnancy. We have identified vinorelbine, a well tolerated chemotherapeutic, as a potential therapeutic for ectopic pregnancy. Vinorelbine potently reduced placental cell viability in-vitro and in-vivo and proved more efficacious than the current medical therapeutic. Vinorelbine did not impact upon subsequent fertility in a mouse breeding model.
Ectopic pregnancy occurs when a conceptus implants outside of the womb. They are life threating and are a leading cause of maternal death in early pregnancy. Currently, the large majority of ectopic pregnancies are removed surgical, partly owing to the limited efficacy of the only available medical therapeutic, methotrexate. Here, we have identified a potential new medical therapeutic for ectopic pregnancy, vinorelbine. Vinorelbine, which is orally available chemotherapeutic, reduced placental cell viability both in-vitro and in-vivo and did not impact upon mice fertility in a breeding model. As such, vinorelbine may be an efficacious treatment for ectopic pregnancy and further human studies into its application are warranted.
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Affiliation(s)
- Roxanne Hastie
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia.
| | - Elgene Lim
- Connie Johnson Breast Cancer Research Group, Garvan Institute of Medical Research, Sydney, Australia
| | - Pavel Sluka
- Uro-Oncology Laboratory, Monash University, Eastern Health Clinical School, Melbourne, Australia
| | - Lisa Campbell
- MRC Centre for Reproductive Health, The University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, The University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | | | - Natalie J Hannan
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
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Parker VL, Srinivas M. Non-tubal ectopic pregnancy. Arch Gynecol Obstet 2016; 294:19-27. [DOI: 10.1007/s00404-016-4069-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/08/2016] [Indexed: 02/07/2023]
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Anderson ML, Ogunwale A, Clark BA, Kilpatrick CC, Mach CM. Preferences and Outcomes for Chemotherapy Teaching in a Postgraduate Obstetrics and Gynecology Training Program. JOURNAL OF SURGICAL EDUCATION 2015; 72:936-941. [PMID: 26119096 DOI: 10.1016/j.jsurg.2015.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/30/2015] [Accepted: 04/13/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE To determine whether chemotherapy teaching is a desired component of postgraduate training programs in obstetrics and gynecology and assess its effect on practicing clinicians. METHOD After obtaining institutional review board approval, 99 individuals who completed postgraduate training at a single academic medical center between 2005 and 2013 were invited to complete an online survey. Descriptive statistics were used to summarize responses. RESULTS Of the 99 individuals, 68 (68%) completed the survey. Respondents included physicians currently practicing in both academic medicine (n = 36, 52.9%) and private practice (n = 24, 35.2%). Most respondents (n = 60, 88.2%) indicated that chemotherapy teaching was a desired feature of their training and expressed a preference for both formal didactics and direct clinical involvement (n = 55, 80.2%). Benefits identified by respondents included improved insight into the management of symptoms commonly associated with chemotherapy (n = 55, 82.1%) and an enhanced ability to counsel patients referred for oncology care (n = 48, 70.5%). All respondents who pursued training in gynecologic oncology following residency (n = 6) indicated that chemotherapy teaching favorably affected their fellowship experience. Of the 6 gynecologic oncologists, 3 (50%) who responded also indicated that chemotherapy teaching during residency improved their performance in fellowship interviews. CONCLUSION Chemotherapy teaching was a desired feature of postgraduate training in general obstetrics and gynecology at the institution studied. Consideration should be given to creating curricula that incorporate the principles and practice of chemotherapy and address the needs of obstetrics and gynecology trainees who intend to pursue both general and subspecialty practice.
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Affiliation(s)
- Matthew L Anderson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.
| | - Abayomi Ogunwale
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Brian A Clark
- Department of Clinical Sciences and Administration, University of Houston, Houston, Texas
| | - Charlie C Kilpatrick
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Claire M Mach
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Department of Clinical Sciences and Administration, University of Houston, Houston, Texas
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Refaat B, Dalton E, Ledger WL. Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies. Reprod Biol Endocrinol 2015; 13:30. [PMID: 25884617 PMCID: PMC4403912 DOI: 10.1186/s12958-015-0025-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment. METHODS The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected. RESULTS A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence. CONCLUSIONS EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-Abdiyah Campus, PO Box 7607, Makkah, KSA.
| | - Elizabeth Dalton
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
| | - William L Ledger
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
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