Ectopic pregnancy

Using Innovative Video Doctor Technology in Primary Care to Deliver Brief Smoking and Alcohol Intervention

Given physicians' increased responsibilities and time constraints, it is increasingly difficult for primary care physicians to assume a major role in delivering smoking and alcohol assessment and intervention. The authors developed an innovative use of computer technology in the form of a “video doctor” to support physicians with this. In this article, two brief interventions, delivered by an interactive, multimedia video doctor, that reduce primary care patients' smoking and alcohol use are detailed: (a) a patient-centered advice message and (b) a brief motivational intervention. The authors are testing the use of the video doctor to deliver these interventions in a randomized, controlled study, Project Choice. A pilot study testing the feasibility and acceptability of the video doctor suggests it was well received and accepted by patients (n = 52) and potentially provides an innovative, cost-effective, and practical way to support providers' efforts to reduce smoking and alcohol use in primary care populations.

Management of women presenting to the accident and emergency department with lower abdominal pain

The diagnosis and management of lower abdominal pain is difficult, particularly for the inexperienced accident and emergency (A&E) or surgical trainee. In women, potential gynaecological causes may further confuse the picture. We analysed the incidence, spectrum of presentation and immediate management of 322 women presenting consecutively to an inner city A&E department over a 6-month period with lower abdominal pain. A standard questionnaire relating to history, examination, immediate investigations and preliminary diagnosis was completed by the attending A&E doctor. The cause of abdominal pain, according to the A&E doctor's diagnosis, was gynaecological in 61%, gastroenterological in 23%, urological in 7% and non-specific in 9% of cases. Of the women, 39% (124/322) were referred to a duty specialist, of whom 86% (107/124) required admission for investigation and/or treatment. Women initially diagnosed as having pain of gynaecological origin formed the largest group of patients to be referred. In 69% (67/97) of these cases, the A&E doctor's initial diagnosis was confirmed by the gynaecologist. This study shows that pain of gynaecological origin was the largest single cause of lower abdominal pain in women presenting to our A&E department and that, in the majority of cases, these women needed to be referred to the duty gynaecologist for immediate treatment. Although overall diagnostic accuracy rate was relatively high, the management of potentially life-threatening gynaecological conditions such as ectopic pregnancy was poor. These results emphasise the need to improve in-service gynaecological training in A&E departments.

Accuracy in diagnosis of ectopic pregnancy by transvaginal ultrasonography

Forty patients suspected to have ectopic pregnancy by transvaginal ultrasonography had surgery. 77.5% were confirmed to have ectopic pregnancy and 10% had other abnormal pelvic findings. The transvaginal approach appears to enable us to diagnose ectopic pregnancy at an earlier date, with the earliest diagnosis made at 4 weeks 0 days of amenorrhoea. In cases of confirmed ectopic pregnancy, the presence of a complex adnexal mass was the most common feature seen on transvaginal ultrasound and its predictability of ectopic pregnancy is enhanced by a concomitant finding of an empty uterus (95%) or free fluid in the Pouch of Douglas (94%) in the presence of a positive hCG test. The significance of transvaginal ultrasound features, and the advantages of transvaginal over transabdominal ultrasound, are discussed.

Nonlaser videolaparoscopic surgery for ectopic gestation

The potential of nonlaser videolaparoscopic surgery for ectopic gestation in a metropolitan public hospital was assessed by the review of the last 16 consecutive women presenting to the author with either a ruptured or an unruptured ectopic pregnancy. Ten of the 16 were treated by the videolaparoscopic techniques of either salpingotomy or aquaexpression, removal of the ectopic pregnancy and pelvic lavage; there were no intra or postoperative complications. HCG levels were monitored to extinction in all but one woman who had a coexistent intrauterine pregnancy. Three of the 10 women have subsequently had intrauterine conceptions and none have had further ectopic gestations. Those women unsuitable for videolaparoscopic therapy had substantial haemorrhage (4), an ovarian ectopic pregnancy (1) and extensive adhesions precluding laparoscopy (1). The techniques of nonlaser videolaparoscopic treatment for tubal ectopic gestation are simple and appropriate in a majority of women presenting with this condition.

Measurement of human chorionic gonadotrophin (hCG): indications and techniques for the clinical laboratory

The structure of human chorionic gonadotrophin (hCG) is so similar to that of luteinizing hormone (LH) that a variety of assay techniques have been devised to differentiate between these two hormones. The principal indications for measurement of hCG using these methods have not changed greatly over the past decade but the improvements in the sensitivity, specificity and the development of assays for free subunits and metabolic fragments have expanded the use of hCG assays. The review discusses the use of hCG measurement in a routine clinical immunoassay laboratory and emphasizes different requirements for clinical situations.

Ultrasound evaluation of ectopic pregnancy including correlation with human chorionic gonadotrophin levels

A total of 267 patients referred for ultrasound examination because of clinical suspicion of ectopic pregnancy were studied prospectively. The outcome was correlated with the ultrasound findings and human chorionic gonadotrophin levels using a quantitative serum assay. The value of the following in the diagnosis of ectopic pregnancy are assessed: ultrasound criteria for early diagnosis of intrauterine pregnancy before visualization of a viable fetus, the discriminatory zone of hCG and extrauterine abnormalities.

The diagnosis of ectopic pregnancy in an accident and emergency department

The correct diagnosis was initially suspected in 32 (53%) of 60 patients with ectopic pregnancy who attended an accident and emergency department. Incorrect diagnoses were made because ectopic pregnancy was not considered or because relevant symptoms and signs were missed or misinterpreted. Three patients had been 'sterilized'. Twenty-four patients (40%) had abdominal pain or vaginal bleeding for more than 1 week before attending. Fever and leucocytosis were wrongly attributed to pelvic infection. Pregnancy tests were positive in 56% of the patients tested.