Time trends of ectopic pregnancies

Ovarian ectopic pregnancy: the role of complex morphopathological assay. Review and case presentation

Ovarian ectopic pregnancy (OEP) represents the rarest type of ectopic pregnancy, accounting for 1-3% of this pathology. The diagnosis of this pathology is challenging due to the non-specific clinical aspects and the ultrasound examination hampered by the lack of visible gestational sac in the presence of hematocele and hemoperitoneum. The purpose of the extended histopathological (HP) examination was to identify particular aspects of the OEP trophoblast and to highlight potential local ovarian modifications which can determine pregnancy fixation at this level. The patient presented local favorable conditions for intraovarian nidation, conditions confirmed by the HP classical examination and by the immunohistochemical evaluation. We identified, using classical Hematoxylin-Eosin, Masson's trichrome and Periodic Acid-Schiff (PAS)-Hematoxylin, necrotic hemorrhage, accentuated vascular thrombosis and high density lymphoplasmocytary infiltrate. These modifications increased local adhesivity and cell destruction through hypoperfusion. Anti-cluster of differentiation antibodies (CD34, CD38, tryptase) revealed the low number of intravillous vessels and the high number of macrophages and mastocytes involved in the local inflammatory process heighten. We identified the presence of trophoblast tissue in the ovarian structure using anti-cytokeratin AE1∕AE3 (CK AE1∕AE3)/anti-cytokeratin 7 (CK7) antibodies. The anti-alpha-smooth muscle actin (α-SMA) and anti-vimentin (VIM) antibodies displayed the density of myofibroblasts and intravillous stromal cells and with the aid of anti-progesterone receptor (PR) antibody, we identified the corpus luteum hormonal response in the OEP. The placental villosities present a blocked multiplication process at the anti-apoptotic B-cell lymphoma 2 (BCL2) protein, confirmed by the Ki67 cell proliferation and tumor protein 63 (p63) immunomarkers. Anti-neuron specific enolase (NSE), anti-calretinin and anti-inhibin A antibodies showed the particular aspects of the granulosa and internal theca cells, which may be involved in oocyte release blockage, intraluteal and extraluteal fecundation of the OEP.

Complications of IVF and ovulation induction

BACKGROUND

The frequency and importance of complications of IVF and other ovulation induction (OI) are poorly known. We examined the occurrence of serious complications and miscarriages leading to hospitalization or operation after IVF (including microinjections and frozen embryo transfers) and OI treatment (with or without insemination).

METHODS

Women who received IVF (n = 9175) or OI treatment (n = 10 254) 1996-1998 in Finland were followed by a register linkage study until 2000.

RESULTS

After the first IVF treatment cycle, 14 per 1000 women had a serious case of OHSS (ovarian hyperstimulation syndrome), with 23 per 1000 throughout the study period (mean of 3.3 treatments). The corresponding values after OI were very low. The rates of registered ectopic pregnancies and miscarriages after IVF were nine and 42 respectively per 1000 women, with corresponding rates after OI of eight and 42. Infections and bleeding were not common after IVF and even rarer after OI. Overall, 15% of IVF and 8% of OI women had at least one hospital episode during the study period.

CONCLUSIONS

Though there was a low risk of complications after each IVF treatment cycle, repeated attempts resulted in serious complications for many women, and these occurred much more often than after ovulation induction alone.

Fecundity and morbidity following acute pelvic inflammatory disease treated with doxycycline and metronidazole

We studied fecundity and late sequelae of 39 women who had laparoscopic and microbiological sampling-proven acute pelvic inflammatory disease (PID) treated with the same antimicrobial regimen. The grade and etiology of index PID were classified using laparoscopy, endometrial biopsy and microbiological cultures from the cervix, endometrium and tubes: 20 had mild and 19 severe PID. The mean (SD) follow-up period after the index PID was 125 (44) [range 8-204] months. The primary end-point was pregnancy. All other or recurrent infections or other diseases related to the infection, including infertility, were evaluated. Twenty (51%) women had laparotomy or second laparoscopy during follow-up and findings were evaluated. Chlamydia trachomatis was isolated in 38% of all cases. Eleven (28%) of 39 women avoided conception or it was no longer possible. Twenty-eight women had tried to conceive after the index PID and 25 (89%) of them had at least one pregnancy. Twenty-five women had 56 pregnancies, 33 (59%) of which ended in delivery, 9 (16%) miscarried, 13 (23%) were induced abortion and only one (1.8%) tubal pregnancy occurred. Etiologic factors or severity of PID made no difference to the conception rate. Patients with mild or moderate salpingitis had a high conception rate. Endometriosis was found in 6 (30%) out of 20 women with second laparoscopy or laparotomy. Hysterectomy had been performed in 4 cases. Precise diagnosis of acute PID is the cornerstone for the treatment of the condition. Combination regimens, including drugs against the most common factors underlying acute PID against both aerobic and anaerobic microbes, prevent late sequelae in cases with mild or moderate salpingitis but not in cases with tubal or pelvic abscess.

Serum levels of smooth muscle heavy-chain myosin in patients with ectopic pregnancy

STUDY OBJECTIVE

Previous studies have suggested that serum markers of smooth muscle destruction have utility in predicting ectopic pregnancy. Our goal was to determine whether a novel marker of muscle destruction, smooth muscle heavy-chain myosin (SMHC), is elevated in the serum of patients with ectopic pregnancy.

METHODS

We conducted a prospective cohort study, with consecutive enrollment, of all women in the first trimester of pregnancy who presented to our urban emergency department with complaints of lower abdominal pain with or without vaginal bleeding. Patients were excluded if there was a history of recent surgery or major trauma. Means were compared using 2-tailed Student's t test with P values less than.05 set for significance. Data analysis included calculation of receiver operating characteristic (ROC), 95% confidence intervals (CIs), and a regression model.

RESULTS

A total of 175 patients were enrolled; ectopic pregnancy was diagnosed in 29, and 146 had other diagnoses. Patients with ectopic pregnancy had a mean serum SMHC concentration of 2.53 ng/dL (95% CI 1.84 to 3.22), whereas those in the non-ectopic pregnancy group had a mean concentration of 1.41 ng/dL (95% CI 1.23 to 1.60; P <.0001). ROC analysis demonstrated an area under the curve of 0.72 (95% CI 0.65 to 0.79). Regression analysis to examine confounders in each group analyzed the effects of race, maternal age, estimated gestational age, and serum levels of human chorionic gonadotropin beta-subunit. Our analysis identified only a positive correlation between estimated gestational age and SMHC in the non-ectopic pregnancy group.

CONCLUSION

There is a statistically significant elevation of serum SMHC levels in tubal pregnancy, although our data suggest that the assay has limited clinical utility as a lone marker for ectopic pregnancy. Further investigation is needed to determine whether the assay has a role as an adjunct in the evaluation of suspected ectopic pregnancy.

Unicornuate uterus and rudimentary horn

OBJECTIVE

To evaluate clinical implications of the unicornuate uterus and rudimentary horn.

DESIGN

A retrospective study.

SETTING

A university hospital.

PATIENT(S)

Forty-two women who had a unicornuate uterus with or without rudimentary horn.

INTERVENTION(S)

The rudimentary horn was removed in 21 cases.

MAIN OUTCOME MEASURE(S)

Presence of other anomalies, fertility, and outcome of pregnancies were studied.

RESULT(S)

A right unicornuate uterus with noncommunicating rudimentary horn was the most common type of uterine anomaly. Unilateral renal agenesis was found in 13 (38%) of 34 cases. Six (14%) of the 42 patients had primary infertility. Thirty-four women produced 93 pregnancies; ectopic pregnancy (EP; rudimentary horn, tubal) occurred in 20 of these cases (22%). The pregnant uterine horn ruptured in 3 of 7 cases. Eight (57%) of the 14 women with infertility underwent treatment by IVF-ET; 4 of them conceived, and 2 had term delivery. The fetal survival rate was 61%, prematurity 17%, fetal growth retardation 5%, and the spontaneous intrauterine (IU) abortion rate was 16%. Pregnancy-induced hypertension (PIH) was more common in women lacking a kidney than in those with two kidneys.

CONCLUSION(S)

The high number of EPs indicates removal of rudimentary horn and its tube when diagnosed. The prognosis of IU pregnancy is not impaired in the unicornuate uterus although prematurity threatens. Unilateral renal agenesis is associated with PIH.

Long-term effects of cesarean sections: ectopic pregnancies and placental problems

OBJECTIVE

Few studies on the long-term effects of cesarean sections exist. The purpose of this study was to investigate the occurrence of three long-term effects, ectopic pregnancy, placenta previa, and abruptio placentae, in the subsequent pregnancy.

STUDY DESIGN

This retrospective cohort study was based on two nationwide registers in Finland: the birth register and the hospital inpatient register. Women (n = 16,938) having had a cesarean section (exposed women) and a matched control group were identified from the birth register. The occurrence and outcome of the first subsequent pregnancy was determined from the 1987 to 1993 hospital inpatient register and the first subsequent birth from the 1987 to 1993 birth register.

RESULTS

During the follow-up time in the hospital inpatient register, fewer exposed women had a completed pregnancy. Ectopic pregnancy was more common among the exposed women than among the controls (risk ratio 1.28). In the first subsequent birth abruptio placentae was more common among primiparous (at index the birth, risk ratios of 3.22 in hospital inpatient register and 2.41 in birth register) and multiparous women (4.52 in hospital inpatient register and 3.89 in birth register). Placenta previa was more common among primiparous exposed women than among control women (risk ratio 5.34 in hospital inpatient register and 3.78 in birth register).

CONCLUSIONS

Cesarean section is a modest risk factor for ectopic pregnancy and an important risk factor for placental problems.

Outcome of pregnancies in women with treated or untreated hyperprolactinemia

The outcome of 103 pregnancies in 64 women with constant hyperprolactinemia was evaluated. Seventy-eight pregnancies had been induced with bromocriptine and 25 occurred without any treatment. In all, 66% of the pregnancies ended in delivery, 17% in miscarriage, 10% in tubal pregnancy and 7% in induced abortion. The pregnancy of women with untreated hyperprolactinemia was more frequently ectopic when compared to those in women treated by bromocriptine. Obstetric complications as well as signs of tumoral enlargement during pregnancy were rare in hyperprolactinemic women treated or untreated with bromocriptine. Untreated hyperprolactinemia as a risk factor in tubal pregnancy is proposed.

An audit of the management of ectopic pregnancy

OBJECTIVE

To estimate the local incidence of ectopic pregnancy and to review the management of ectopic pregnancy with reference to those misdiagnosed at presentation. To establish management guidelines to be applied to all possible ectopic pregnancies.

DESIGN

A review of all ectopic pregnancies presenting over a 2-year period, and of emergency gynaecological admissions during 4 months.

SETTING

A teaching hospital.

RESULTS

The local rate of ectopic pregnancy was similar to that seen in other UK studies. Nineteen (13%) women with ectopic pregnancies were sent home with an incorrect diagnosis. Eight were recalled but eight required emergency admission and one died at home. Undue confidence in ultrasound reports and failure to follow up inconclusive histology results were a feature in cases where patients were not recalled. A set of simple management guidelines has been drawn up. Amongst general gynaecological admissions 1 in 12 of all first trimester complications was an ectopic pregnancy. Amongst apparently true uterine miscarriages 20% of histological examinations were inconclusive and histology and ultrasound examinations failed to confirm a uterine miscarriage in 14% of apparently true missed miscarriages.

CONCLUSIONS

Ectopic pregnancy is common amongst first trimester complications. Adherence to simple management guidelines would minimize the number of patients requiring emergency admission, though up to 20% of patients with apparently true uterine miscarriages would also require further investigation.

Ectopic pregnancy in Zimbabwe

One hundred four consecutive ectopic pregnancies were systematically analysed. During the study period, the incidence rate was 110 per 100,000 14-44 year old females per year. A history of prior pelvic infection was given by 53.8% of the cases and was suggested by surgical findings or by histological analysis among 74.9%. Serological evidence of previous chlamydial infection was much more common when ectopic pregnancy occurred in abnormal tubes than in normal tubes or compared to intrauterine pregnancies. The influence of schistosomiasis, endometriosis and ovarian cyst was limited to a very few cases. The analysis of contraceptive habits shows a much higher number of extrauterine pregnancies when the woman is using progestin-only pill than when she is on combined oral tablets.

Long term maternal health effects of caesarean section

OBJECTIVE

The aim was to study whether women having had caesarean sections (index women) have more subsequent health problems, measured by hospital admissions, than women having had vaginal deliveries (control women).

DESIGN

The study involved comparison of hospital admissions before (2-5 years) and after (7-10 years) the first caesarean section (exposure) among two cohorts of index and control women.

SETTING

National data from the Swedish birth and hospital discharge registries were used.

PARTICIPANTS

About 75% of all Swedish primiparas who had a caesarean section in 1973 (n = 2578) and in 1976 (n = 3822), and their age-matched controls, were studied; non-Swedish women and women with certain specific problems at their first birth were excluded.

MEASUREMENTS AND MAIN RESULTS

Numbers of discharges from general and mental hospitals excluding discharges relating to birth, and in some analyses to pregnancy, were determined. Total numbers of discharges from general and mental hospitals, and the numbers of discharges with operations, were higher among index than control women both before and after exposure. In analyses by diagnosis, a caesarean section was a risk factor for ectopic pregnancies and sterilisations.

CONCLUSIONS

The analyses suggest that the higher rate of hospital admission after caesarean section than after vaginal delivery is not due to the section itself, but to a continuation of a previous pattern of health service use. However, because this was not so for all diagnoses and alternative interpretations are possible, further studies on long term maternal morbidity are needed.

Induced abortions, contraceptive practices, and tobacco smoking as risk factors for ectopic pregnancy in Athens, Greece

A case-control study of the role of induced abortion and other factors on the subsequent occurrence of ectopic pregnancy was undertaken in 1986-1987 in Athens, Greece, where a similar study 20 years ago found a tenfold risk of ectopic pregnancy among women with one or more illegal induced abortions. Seventy women residents of Athens, consecutively admitted to the major state maternity hospital with a diagnosis of ectopic pregnancy, were individually matched with women with a newly diagnosed pregnancy of the same order as the ectopic index pregnancy. Two control women were found for each of 63 cases, but only one control for each of the remaining seven cases. All cases and controls were interviewed by the same qualified obstetrician. Statistical analysis was undertaken with stratification of individual matched triplets and pairs, as well as through conditional multiple regression procedures. The relative risk of recurrence of an ectopic pregnancy was 6.39 with 95% confidence interval (CI) 1.96-21.04. Miscarriages did not increase the risk of ectopic pregnancy. The relative risk for subsequent ectopic pregnancy among women with one or more induced abortion, compared to women without such abortions, was 1.87 (CI 0.84-4.16) controlling only for the matching factors, and 1.71 (CI 0.69-4.27) when marital status (a possible selection factor) was also accounted for in the conditional logistic regression. There was no evidence for increasing risk with increasing number of induced abortions. Past use of an intrauterine device (IUCD) was associated with a relative risk of 3.89 (0.72-21.02); the relative risk increased with the duration of use of the IUCD.(ABSTRACT TRUNCATED AT 250 WORDS)

The regional versus national incidence of ectopic pregnancy in Finland from 1966 to 1986

The annual incidence of ectopic pregnancy (EP) per deliveries, per all diagnosed pregnancies and per female population at fertile age (15-44 years) were measured from 1966 to 1986 in a well-defined urban area of Southwestern Finland, the Turku Region. The incidence rates increased markedly, and were, in the mid-80s, among the highest in the world: 2.6 per 100 deliveries, 1.8 per 100 diagnosed pregnancies and 153 per 100,000 fertile-aged women. The regional incidence rate exceeded the national one in the 1970s, whereas in the 1980s the regional rate which has levelled-off during recent years has been equal to, and currently even lower than the national one. This suggests that changes in the incidence of EP in urban area(s) preceed those in the whole country.

Ectopic pregnancy in Aberdeen 1950-1985

The reported incidence of ectopic pregnancy in Aberdeen City and suburbs (1950-1985), using as denominators maternities, pregnancies and women aged 15-44 years, has increased threefold since 1970 to 6.4/1000 pregnancies. This increased incidence persisted after the exclusion of previously sterilized women. A total of 11,128 women were sterilized in Aberdeen City and suburbs between 1960 and 1982; 36 ectopic pregnancies occurred in this sterilized population. The prevalence of ectopic pregnancy was 3.55/1000 sterilizations. This did not alter significantly over the period of study despite changes in the method of sterilization. However, due to the increased popularity of sterilization, the proportion of ectopic pregnancies in women who had been sterilized increased from 0% in the 1950s to 21% in the quinquennium 1975-1979.