Accuracy of single progesterone test to predict early pregnancy outcome in women with pain or bleeding: meta-analysis of cohort studies

Diagnostic utility of clinicodemographic, biochemical and metabolite variables to identify viable pregnancies in a symptomatic cohort during early gestation

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.

Exploring Progesterone Deficiency in First-Trimester Miscarriage and the Impact of Hormone Therapy on Foetal Development: A Scoping Review

Background and Objectives: Progesterone deficiency during pregnancy may lead to various complications, including first-trimester miscarriage, which is the most common pregnancy complication. However, progesterone therapy may play a role in pregnancy maintenance and foetal development. The aim of this scoping review is to present evidence on the link between progesterone deficiency and first-trimester miscarriage among pregnant women and assess the impact of progesterone therapy on foetal development. Methods: A comprehensive global systematic search of mainly primary research studies was conducted using several databases. Peer-reviewed studies published between 2010 and 2023 were included. The scoping review was conducted using the framework outlined by the Joanna Briggs Institute (JBI) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR) statement. Results: Twenty-three articles (which included 35,862 participants) were included in the analysis. Most studies were conducted in mid- to high-income countries. All 23 articles reported a significant positive relationship between progesterone deficiency and first-trimester miscarriage. Furthermore, the majority of studies reported a higher risk of miscarriage when lower levels of progesterone are combined with other declined hormones. While most studies reported that progesterone therapy may reduce the rate of first-trimester miscarriage among pregnant women, no evidence of health-related harm to offspring development was reported. Conclusions: The findings from this systematic-scoping review indicate possible benefits of progesterone replacement therapy in maintaining a healthy pregnancy and foetal development. Rigorous studies that include large sample sizes and systematic reviews are required to confirm these findings further.

Can single progesterone concentration predict miscarriage in early pregnant women with threatened miscarriage: a systematic review and meta-analysis

BACKGROUND

About 25% of pregnant women experience bleeding in the early stage, and half of them eventually progress to pregnancy loss. Progesterone serves as a useful biomarker to predict miscarriage in threatened miscarriage, yet its performance is still debated.

AIM

To evaluate the performance of single serum progesterone predicting miscarriage in early pregnant patients with threatened miscarriage.

METHOD

The online database was searched to yield the literature using the terms of 'Abortion', 'Miscarriage', and 'serum Progesterone', including PubMed, Scopus, Embase, Cochrane library, and China national knowledge infrastructure. Receiver operating characteristic (ROC) curve, likelihood ratio (LLR) and diagnostic odds ratio (DOR) and 95% confidence interval (CI) were computed. Publication bias was assessed by the deeks funnel plot asymmetry test. Subgroup analyses were conducted according to the progesterone level (< 12 ng/mL), recruited location and region, progesterone measurement method, exogenous progesterone supplement and follow up.

RESULTS

In total, 12 studies were eligible to be included in this study, with sample sizes ranging from 76 to 1087. The included patients' gestational age was between 4 and 12 weeks. No significant publication bias was detected from all included studies. The threshold of progesterone reported ranged from 8 to 30 ng/ml. The synthesized area under the ROC curve (0.85, 95% CI 0.81 to 0.88), positive LLR (6.2, 4.0 to 9.7) and DOR (18, 12 to 27) of single progesterone measurement distinguishing miscarriage were relatively good in early pregnant patients with threatened miscarriage. When the threshold of < 12 ng/mL was adapted, the progesterone provided a higher area under the ROC curve (0.90 vs. 0.78), positive LLR (8.3 vs. 3.8) and DOR (22 vs.12) than its counterpart (12 to 30 ng/mL).

CONCLUSION

Single progesterone measurement can act as a biomarker of miscarriage in early pregnant patients with threatened miscarriage, and it has a better performance when the concentration is <12 ng/mL.

TRIAL REGISTRATION

PROSPERO (CRD42021255382).

Usability, accuracy, and cost-effectiveness of a medical software for early pregnancies: a retrospective study

STUDY QUESTION

Can early pregnancies be accurately and cost-effectively diagnosed and managed using a new medical computerized tool?

SUMMARY ANSWER

Compared to the standard clinical approach, retrospective implementation of the new medical software in a gynaecological emergency unit was correlated with more accurate diagnosis and more cost-effective management.

WHAT IS KNOWN ALREADY

Early pregnancy complications are responsible for a large percentage of consultations, mostly in emergency units, with guidelines becoming complex and poorly known/misunderstood by practitioners.

STUDY DESIGN, SIZE, DURATION

A total of 780 gynaecological emergency consultations (446 patients), recorded between November 2018 and June 2019 in a tertiary university hospital, were retrospectively encoded in a new medical computerized tool. The inclusion criteria were a positive hCG test result, ultrasonographical visualization of gestational sac, and/or embryo corresponding to a gestational age of 14 weeks or less. Diagnosis and management suggested by the new computerized tool are named eDiagnoses, while those provided by a gynaecologist member of the emergency department staff are called medDiagnoses.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Usability was the primary endpoint, with accuracy and cost reduction, respectively, as secondary and tertiary endpoints. Identical eDiagnoses/medDiagnoses were considered as accurate. During follow-up visits, if the updated eDiagnoses and medDiagnoses became both identical to a previously discrepant eDiagnosis or medDiagnosis, this previous eDiagnosis or medDiagnosis was also considered as correct. Four double-blinded experts reviewed persistent discrepancies, determining the accurate diagnoses. eDiagnoses/medDiagnoses accuracies were compared using McNemar's Chi square test, sensitivity, specificity, and predictive values.

MAIN RESULTS AND THE ROLE OF CHANCE

Only 1 (0.1%) from 780 registered medical records lacked data for full encoding. Out of the 779 remaining consultations, 675 eDiagnoses were identical to the medDiagnoses (86.6%) and 104 were discrepant (13.4%). From these 104, 60 reached an agreement during follow-up consultations, with 59 medDiagnoses ultimately changing into the initial eDiagnoses (98%) and only one discrepant eDiagnosis turning later into the initial medDiagnosis (2%). Finally, 24 remained discrepant at all subsequent checks and 20 were not re-evaluated. Out of these 44, the majority of experts agreed on 38 eDiagnoses (86%) and 5 medDiagnoses (11%, including four twin pregnancies whose twinness was the only discrepancy). No majority was reached for one discrepant eDiagnosis/medDiagnosis (2%). In total, the accuracy of eDiagnoses was 99.1% (675 + 59 + 38 = 772 eDiagnoses out of 779), versus 87.4% (675 + 1 + 5 = 681) for medDiagnoses (P < 0.0001). Calculating all basic costs of extra consultations, extra-medications, extra-surgeries, and extra-hospitalizations induced by incorrect medDiagnoses versus eDiagnoses, the new medical computerized tool would have saved 3623.75 Euros per month. Retrospectively, the medical computerized tool was usable in almost all the recorded cases (99.9%), globally more accurate (99.1% versus 87.4%), and for all diagnoses except twinning reports, and it was more cost-effective than the standard clinical approach.

LIMITATIONS, REASONS FOR CAUTION

The retrospective study design is a limitation. Some observed improvements with the medical software could derive from the encoding by a rested and/or more experienced physician who had a better ultrasound interpretation. This software cannot replace clinical and ultrasonographical skills but may improve the compliance to published guidelines.

WIDER IMPLICATIONS OF THE FINDINGS

This medical computerized tool is improving. A new version considers diagnosis and management of multiple pregnancies with their specificities (potentially multiple locations, chorioamnionicity). Prospective evaluations will be required. Further developmental steps are planned, including software incorporation into ultrasound devices and integration of previously published predictive/prognostic factors (e.g. serum progesterone, corpus luteum scoring).

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. F.B. and D.G. created the new medical software.

TRIAL REGISTRATION NUMBER

NCT03993015.

The effect of frozen embryo transfer regimen on the association between serum progesterone and live birth: a multicentre prospective cohort study (ProFET)

STUDY QUESTION

What is the association between serum progesterone levels on the day of frozen embryo transfer (FET) and the probability of live birth in women undergoing different FET regimens?

SUMMARY ANSWER

Overall, serum progesterone levels <7.8 ng/ml were associated with reduced odds of live birth, although the association between serum progesterone levels and the probability of live birth appeared to vary according to the route of progesterone administration.

WHAT IS KNOWN ALREADY

Progesterone is essential for pregnancy success. A recent systematic review showed that in FET cycles using vaginal progesterone for endometrial preparation, lower serum progesterone levels (<10 ng/ml) were associated with a reduction in live birth rates and higher chance of miscarriage. However, there was uncertainty about the association between serum progesterone levels and treatment outcomes in natural cycle FET (NC-FET) and HRT-FET using non-vaginal routes of progesterone administration.

STUDY DESIGN SIZE DURATION

This was a multicentre (n = 8) prospective cohort study conducted in the UK between January 2020 and February 2021.

PARTICIPANTS/MATERIALS SETTING METHODS

We included women having NC-FET or HRT-FET treatment with progesterone administration by any available route. Women underwent venepuncture on the day of embryo transfer. Participants and clinical personnel were blinded to the serum progesterone levels. We conducted unadjusted and multivariable logistic regression analyses to investigate the association between serum progesterone levels on the day of FET and treatment outcomes according to the type of cycle and route of exogenous progesterone administration. Our primary outcome was the live birth rate per participant.

MAIN RESULTS AND THE ROLE OF CHANCE

We studied a total of 402 women. The mean (SD) serum progesterone level was 14.9 (7.5) ng/ml. Overall, the mean adjusted probability of live birth increased non-linearly from 37.6% (95% CI 26.3-48.9%) to 45.5% (95% CI 32.1-58.9%) as serum progesterone rose between the 10th (7.8 ng/ml) and 90th (24.0 ng/ml) centiles. In comparison to participants whose serum progesterone level was ≥7.8 ng/ml, those with lower progesterone (<7.8 ng/ml, 10th centile) experienced fewer live births (28.2% versus 40.0%, adjusted odds ratio [aOR] 0.41, 95% CI 0.18-0.91, P = 0.028), lower odds of clinical pregnancy (30.8% versus 45.1%, aOR 0.36, 95% CI 0.16-0.79, P = 0.011) and a trend towards increased odds of miscarriage (42.1% versus 28.7%, aOR 2.58, 95% CI 0.88-7.62, P = 0.086). In women receiving vaginal progesterone, the mean adjusted probability of live birth increased as serum progesterone levels rose, whereas women having exclusively subcutaneous progesterone experienced a reduction in the mean probability of live birth as progesterone levels rose beyond 16.3 ng/ml. The combination of vaginal and subcutaneous routes appeared to exert little impact upon the mean probability of live birth in relation to serum progesterone levels.

LIMITATIONS REASONS FOR CAUTION

The final sample size was smaller than originally planned, although our study was adequately powered to confidently identify a difference in live birth between optimal and inadequate progesterone levels. Furthermore, our cohort did not include women receiving oral or rectal progestogens.

WIDER IMPLICATIONS OF THE FINDINGS

Our results corroborate existing evidence suggesting that lower serum progesterone levels hinder FET success. However, the relationship between serum progesterone and the probability of live birth appears to be non-linear in women receiving exclusively subcutaneous progesterone, suggesting that in this subgroup of women, high serum progesterone may also be detrimental to treatment success.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by CARE Fertility and a doctoral research fellowship (awarded to P.M.) by the Tommy's Charity and the University of Birmingham. M.J.P. is supported by the NIHR Birmingham Biomedical Research Centre. S.F. is a minor shareholder of CARE Fertility but has no financial or other interest with progesterone testing or manufacturing companies. P.L. reports personal fees from Pharmasure, outside the submitted work. G.P. reports personal fees from Besins Healthcare, outside the submitted work. M.W. reports personal fees from Ferring Pharmaceuticals, outside the submitted work. The remaining authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04170517.

Performance of single serum progesterone in the evaluation of symptomatic first-trimester pregnant patients: a systematic review and meta-analysis

OBJECTIVES

Pain and bleeding complicate 30% of pregnancies, raising concerns for viability. The objective is to evaluate the diagnostic characteristics of a single serum progesterone level in assessing pregnancy viability among symptomatic patients.

METHODS

We conducted a predefined literature search in MEDLINE, Embase (OVID), CINAHL and Cochrane databases for studies that enrolled patients in first trimester with miscarriage symptoms, measured progesterone and reported pregnancy viability, from inception to July 2020. We extracted data for 2 × 2 tables, progesterone threshold levels and viability. We obtained summary estimates of sensitivity, specificity, Diagnostic Odds Ratio (DOR), and predictive values at given prevalence rates.

RESULTS

We identified 54 publications. There was a total of 15,878 patients enrolled, of whom 7864 patients (49.5%) were confirmed to have a viable pregnancy and 8014 patients (50.5%) were confirmed to have a non-viable pregnancy. The cut-off value of progesterone ranged from 3.2 to 25 ng/mL (20.034-79.5 nmol/L). We evaluated the performance of the following progesterone cut-off categories: < 6.3, 6.3-12.6, 12.7-19.9, and 20-25 ng/mL. To detect non-viable pregnancy, progesterone with cut-off < 6.3 ng/mL had sensitivity 73.1%, specificity 99.2% and DOR 322.0 (PPV 0.91, 0.97 and 0.99 at prevalences 0.1, 0.25, 0.5, respectively, indicating higher likelihood of non-viable pregnancy), and cut-off category 20-25 ng/mL had sensitivity 91.3%, specificity 75% and DOR 31.4 (NPV 0.99, 0.96 and 0.89 at the prevalences above indicating higher likelihood of viable pregnancy).

CONCLUSION

A single progesterone level provides a clinically useful prognostic information on pregnancy viability. More than nine out of ten patients with a level < 6.3 ng/mL (< 20.034 nmol/L) will be diagnosed with a non-viable pregnancy, and more than 90% of patients with a level ≥ 20-25 ng/mL (63.6-79.5 nmol/L) will have a viable pregnancy confirmed.

Effects of Different Progesterone Doses on the Concentrations of Proinflammatory and Anti-inflammatory Cytokines in Pregnant Women With Threatened Abortion

Background and objective

This study aimed to investigate how different doses of progesterone influence the concentrations of interleukin-6 (IL-6) and tumor necrotizing factor-alpha (TNF-α), which are proinflammatory cytokines, as well as that of IL-10, which is an anti-inflammatory cytokine, in pregnant women with threatened abortion.

Materials and methods

This is a prospective, single-center, randomized controlled trial conducted with 221 patients with a threatened abortion diagnosis. Group 1 consisted of IL-6, IL-10, and TNF-α values in pre-treatment blood samples from 221 patients diagnosed with imminent abortion. Group 2 included 81 patients who received natural oral 100 mg micronized progesterone MP twice a day for two weeks. Group 3 included 83 patients who were administered oral 200 mg of natural micronized progesterone MP twice a day for two weeks. Group 4 included 57 patients who received oral 200 mg of natural micronized progesterone MP twice a day for two weeks, and one depot progesterone was added to the treatment by administering it at a dosage of 500 mg/day intramuscularly.

Results

IL-6 values between groups were lower in group 4 compared to group 3 (p=0.007). When IL-10 values were compared between the groups, the IL-10 ratio was highest in group 4 and lowest in group 2 (p<0.001, p=0.003, p<0.001). When the TNF-α values between the groups were compared, the value in group 4 was decreased compared to groups 1 and 2 (p=0.031, p<0.001). In the logistic regression analysis, the IL-6 value above 12.01 increased the abortion imminens rate 1.01 times, and a TNF-α value above 11.04 increased the abortion imminens rate 1.21 times.

Conclusion

Progesterone used to treat imminent abortion reduces the levels of proinflammatory cytokines, such as IL-6 and TNF-α, while increasing those of anti-inflammatory cytokine IL-10 in proportion to the dose administered. Progesterone can prevent imminent abortion by generating an anti-inflammatory environment.

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.

Pregnancy-related complications and perinatal outcomes following progesterone supplementation before 20 weeks of pregnancy in spontaneously achieved singleton pregnancies: a systematic review and meta-analysis

BACKGROUND

Progesterone supplementation is widely performed in women with threatened miscarriage or a history of recurrent miscarriage; however, the effects of early progesterone supplementation on pregnancy-related complications and perinatal outcomes in later gestational weeks remain unknown.

METHODS

Ovid MEDLINE, the Cochrane Library, Embase and ClinicalTrials.gov were searched until April 3rd, 2021. Randomized controlled trials regarding spontaneously achieved singleton pregnancies who were treated with progestogen before 20 weeks of pregnancy and were compared with those women in unexposed control groups were selected for inclusion. We performed pairwise meta-analyses with the random-effects model. The risk of bias was assessed according to the Cochrane Collaboration tool. The primary outcomes included preeclampsia (PE), and gestational diabetes mellitus (GDM), with the results presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We identified nine eligible studies involving 6439 participants. The pooled OR of subsequent PE following early progestogen supplementation was 0.64 (95% CI 0.42-0.98, moderate quality of evidence). A lower OR for PE was observed in the progestogen group when the subgroup analysis was performed in the vaginal subgroup (OR 0.62, 95%CI 0.40-0.96). There was insufficient evidence of a difference in the rate of GDM between pregnant women with early progestogen supplementation and unexposed pregnant women (OR 1.02, 95% CI 0.79-1.32, low quality of evidence). The pooled OR of low birth weight (LBW) following oral dydrogesterone was 0.57 (95% CI 0.34-0.95, moderate quality of evidence). The results were affected by a single study and the total sample size of enrolled women did not reach the required information size.

CONCLUSION

Use of vaginal micronized progesterone (Utrogestan) in spontaneously achieved singleton pregnancies with threatened miscarriage before 20 weeks of pregnancy may reduce the risk of PE in later gestational weeks. Among spontaneously achieved singleton pregnancies with threatened miscarriage or a history of recurrent miscarriage, use of oral dydrogesterone before 20 weeks of pregnancy may result in a lower risk of LBW in later gestational weeks. However, the available data were not sufficient to reach definitive conclusions, which highlighted the need for future studies.

Changes in the level of fetoplacental complex hormones in pregnant women with miscarriage

The purpose of the study was TO analyze the fetoplacental complex hormone levels and changes in their dynamics in pregnant women with miscarriage and the impact of these features on the subsequent course of pregnancy. Hormone levels were determined at different stages of gestation in 50 healthy women with a physiological course of pregnancy (control group) and 50 pregnant women with a history of miscarriage (main group). The women of the main group had a significantly slower rate of increase in hormones and a lag in quantitative indicators than the control group. The estradiol level indicators were 4.1 times (76.0%) and 2.89 times (65.5%) lower in women with miscarriage in the embryonic and late fetal period, respectively, compared to healthy women. Indicators of the level of placental lactogen and chorionic gonadotropin in the embryonic period in women with miscarriage were lower by 39.1% and 50.9%, respectively, compared to healthy women. In the late fetal period, the level of these hormones was lower by 72.9% and 35.4%, respectively. In the embryonic and late fetal periods, progesterone levels were lower by 67.4% and 68.4%, respectively, compared to the control group. The data obtained are evidence of a pronounced hormonal abnormality of the placenta, and hence a marker of fetoplacental dysfunction, which on the background of miscarriage develops at the early stages and continues to progress with the course of pregnancy.

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.

An intrauterine genomic classifier reliably delineates the location of nonviable pregnancies

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.

Corpus luteum score, a simple Doppler examination to prognose early pregnancies

OBJECTIVES

In early pregnancies, miscarriages and inconclusive ultrasound scans considering location and viability are very common. In several previous studies, serum progesterone levels predicted viability of pregnancy and, in recent ones, failed Pregnancies of Unknown Location (PUL), completion of miscarriage and complications. Corpus luteum, secreting progesterone in early pregnancy, was less studied. Some publications showed correlations between corpus luteum aspects and diagnosis of miscarriage but it was not evaluated for other outcomes in early pregnancy, such as failed PUL, completion of miscarriage or complications. We aimed to assess if Doppler examination of corpus luteum could also predict all these outcomes: failed PUL, diagnosis and completion of miscarriages and complications.

STUDY DESIGN

A single operator prospectively described and/or collected pictures of Doppler signal in the wall of the corpus luteum at most consultations in our early pregnancy unit and established a three-level score. All suspected or confirmed non-viable pregnancies with this score or/and serum progesterone levels were registered retrospectively. With logistic regressions, AIC/BIC, likelihood ratios, ROC curves, Mann-Whitney and Fisher exact tests, we evaluated the ability of the score, alone, to predict failed PUL, diagnosis and completion of miscarriages and the complications, and, combined, to improve previously published predictions.

RESULTS

From 277 included pregnancies, 186 (67.1 %) miscarried. Of these, 159/186 (85.5 %) fully evacuated without surgery: 114/186 (61.3 %) within 20 days after the first diagnosis and 45/186 (24.2 %) after more than 20 days. Twenty-seven patients (14.5 %) underwent surgical evacuation, including ten complications, five haemorrhages and five suspected infections. Logistic regression correlated strongly the corpus luteum score with failed PUL (p < 0.0001) and miscarriages (p < 0.0001). Moreover, rates of complications and swift non-surgical completions of miscarriage were respectively 0 % and 92 % with scores of 0, versus 6 % and 44 % with scores of 1, versus 16 % and 0 % with scores of 2. Combined with serum progesterone levels, this score improved most predictions. Adding parity or history of miscarriage in predictive models even increased these performances.

CONCLUSIONS

Corpus luteum score, alone, can predict failed PUL, diagnosis and completion of miscarriages and their complications. Combining this score with other factors (mainly serum progesterone levels) improves most predictions.

Comparison of Frozen Embryo Transfer Outcomes Between Uterine Infusion of Granulocyte Colony-Stimulating Factor and Growth Hormone Application in Patients With Thin Endometrium: A Retrospective Study

OBJECTIVE

To investigate the effect of two treatments on the outcome of freeze-thaw embryo transfer for pregnancy assistance in thin endometrium.

METHODS

A retrospective study was conducted on 66 patients who failed in the first cycle treated in the reproductive medicine center of the Second Hospital of Hebei Medical University from January 2018 to December 2019. Granulocyte colony stimulating factor (G-CSF) was used through cavity infusion in one group (n=25, and growth hormone (GH) was subcutaneously injected in the group (n=41). The clinical data of the two groups were compared, including morphology and thickness of the endometrium, biochemical pregnancy rate, clinical pregnancy rate, implantation rate, miscarriage rate, and live birth rate in each period of the hormone replacement cycle.

RESULTS

There was no significant difference in age, BMI, AMH, FSH, LH, E₂, infertility years, number of transferred embryos, basal endometrium, and thickness of endometrium on the day of P administration before and after treatment (P> 0.05). After treatment, compared to the GH group, the G-CSF group presented higher biochemical pregnancy rate (56% versus 48.8%; P=0.569), clinical pregnancy rate (52% versus 46.3%; P=0.655), implantation rate (34.8% versus 27.5%; P=0.391), and live birth rate (40% versus 31.7%; P=0.493), but the differences were not statistically significant (P > 0.05). On the 5th day of treatment, the endometrial thickness in the G-CSF group was thinner than that in the GH group (4.83 ± 0.85 versus 5.75 ± 1.27; P< 0.05), but it had no correlation with pregnancy outcome (P > 0.05). There was no significant difference in endometrial thickness between the two groups on the 7th, 9th day of treatment and the day of P administration (P > 0.05). On the 5th day of treatment, the proportion of endometrial type A morphology in the GH group was significantly higher than that in the G-CSF group (P < 0.05), while the type B morphology in the G-CSF group was significantly higher than that in the GH group (P< 0.05).

CONCLUSION

Although G-CSF and GH may not have a role in increasing endometrium, both of them can improve the pregnancy outcomes of patients with thin endometrium in the FET cycle. And the effects of the two treatments were similar.

Reproducibility of saliva progesterone measured by immunoassay compared to liquid chromatography mass spectrometry

Immunoassay overestimates progesterone in blood, but no studies have tested whether this occurs in saliva. We measured progesterone in saliva using immunoassay and mass spectrometry. We tested the immunoassay for cross reactivity with dehydroepiandrosterone sulfate (DHEA-S) and 17α-hydroxyprogesterone (17α-OHP). Progesterone was significantly higher in immunoassay compared to mass spectrometry. Immunoassay progesterone levels increased in when incremental levels of 17α-OHP standard was added. This effect was not observed with the addition of DHEA-S. Research using salivary progesterone immunoassay techniques should be wary, particularly with individuals taking steroid supplementation or with high levels of progesterone metabolites.

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.

Can neutrophil-to-lymphocyte and monocyte-to-lymphocyte ratios be useful markers for predicting missed abortion in the first trimester of pregnancy?

AIM

To explore whether neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) could predict missed abortion (MA) at 7-13 week's gestation.

METHODS

A total of 363 women with a diagnosis of MA and 232 women with normal pregnancy at 7-13 week's gestation, who visited our hospital from June 2012 to May 2018 were retrospectively analyzed. At 7 week's gestation, total and differential leukocyte counts, NLR and MLR were compared between women with MA (n = 69) and normal controls (n = 53). The receiver operating characteristic curve was used to select the optimal indicator and its cut-off point. The role of the optimal indicator was further assessed at 8-13 week's gestation.

RESULTS

The mean white blood cell counts, the mean neutrophil counts, the median monocyte counts, the mean NLR and the median MLR in women with MA were significantly lower than those in normal controls (P < 0.05, respectively).The neutrophil counts had the highest area under the curve (AUC) value of 0.772 (95% confidence interval 0.675-0.869) with a cut-off value of 4.870 × 10⁹ /L, and the sensitivity was 72.46%, the specificity was 69.81%, positive predictive value was 75.76%, and negative predictive value was 66.07%. In addition, the neutrophil counts were also significantly lower in MA groups than those in normal controls at 8-13 week's gestation, and all had the highest AUC values.

CONCLUSION

Neutrophil counts may predict MA in the first trimester of pregnancy, which may provide a promising marker to diagnose missed abortion as early as 7 week's gestation.

Increased Circulating Levels of Tissue-Type Plasminogen Activator Are Associated with the Risk of Spontaneous Abortion During the First Trimester of Pregnancy

Spontaneous abortion is a common complication in early pregnancy, with an incidence of around 20%. Ultrasound scan and measurement of human chorionic gonadotropin are used to identify patients at risk of spontaneous abortion; however, there is a clinical need to find new biomarkers to prospectively identify patients before the onset of clinical symptoms. Here, we aim to investigate potential biomarkers of spontaneous abortion taken in the first clinical appointment of pregnancy. A case–control study was conducted based on a prospectively collected cohort in which cases and controls were retrospectively stratified based on pregnancy outcome: normal healthy pregnancies (controls = 33) and pregnancies that ended in spontaneous abortion (cases = 10). We evaluated extracellular vesicles isolated by precipitation with ExoQuick™ and protein concentrations of tissue plasminogen activator, leptin, and adiponectin measured by ELISA. The extracellular vesicles showed the typical morphology and membrane proteins: CD63, Alix, and Flotilin-1. The size distributions of the isolated extracellular vesicles were 112 ± 27 and 118 ± 28 nm in diameter for controls and spontaneous abortion, respectively, and the total amount of extracellular vesicles did not show any difference between controls and the spontaneous abortion group. The tissue plasminogen activator showed a significant difference (p = 0.0004) between both groups, although neither adiponectin nor leptin revealed significant changes, indicating that women who had spontaneous abortions have significantly higher levels of tissue plasminogen activator than women who had normal pregnancies.

Soluble urokinase plasminogen activator receptor (suPAR) as a biomarker of early pregnancy location and viability compared with hCG, progesterone and estradiol

A circulating biomarker of early pregnancy outcome independent of ultrasonography and gestational age is a coveted goal. This study evaluated soluble urokinase plasminogen activator receptor (suPAR), a well-described marker of inflammation and immunological activation, for this purpose, and compared it with established early pregnancy biomarkers of the luteoplacental phase: progesterone, estradiol and hCG. We merged data from two prospective first trimester cohorts to conduct a case-control study comparing these analytes in women who had either a live birth, a miscarriage or an ectopic pregnancy. The ability to predict pregnancy location and viability was assessed by areas under the receiver operating characteristic curves (AUC). Comparing women irrespective of gestational age with a live birth, miscarriage or ectopic pregnancy showed significantly lower suPAR values in the latter group (2.4 vs. 2.4 vs. 2.0 μg/L, p = 0.032, respectively), as were all other analytes. Before 6 weeks' gestation, suPAR was significantly inferior to progesterone, estradiol and hCG in pregnancy location and viability prediction (in 124 pregnancies, suPAR AUC_location = 0.69 [CI: 0.54-0.83] and AUC_viability = 0.58 [CI: 0.48-0.69], while progesterone AUC_location = 0.95 [CI: 0.87-1.00] and AUC_viability = 0.84 [CI: 0.75-0.92]). After 6 weeks' gestation, suPAR prediction improved but was inferior to hCG, progesterone and estradiol (in 188 pregnanices, suPAR AUC_location = 0.71 [CI: 0.63-0.78] and AUC_viability = 0.70 [CI: 0.63-0.78] compared with hCG AUC_location = 0.96 [CI: 0.93-0.99] and AUC_viability = 0.96 [CI: 0.93-0.98]). Collectively, suPAR is less useful as a predictor of early pregnancy outcome than hCG, progesterone and estradol.

Predictive Value of Single Serum Progesterone Level for Viability in Threatened Miscarriage

BACKGROUND

Bleeding is commonly seen during early pregnancy, and predicting the outcome of pregnancy in such cases is a difficult task. The aim of our study was to evaluate the predictive value of single serum progesterone level for finding the viability in threatened miscarriage and to determine the cut-off value for a viable ongoing pregnancy.

METHODS

This was a prospective study in which patients attending the OPD with early pregnancy and bleeding were recruited. Inclusion criteria were period of amenorrhoea less than 12 weeks, complaints of bleeding per vaginum with or without lower abdominal pain and positive urine pregnancy test or serum beta HCG. Multiple pregnancies, inevitable miscarriage, ectopic pregnancy, molar pregnancy and pregnancy achieved by artificial reproductive techniques were excluded from this study. A detailed clinical examination was done, and routine investigations along with serum progesterone were done. Patients were followed up by serial ultrasound for viability, and their outcome was recorded.

RESULT

A total of 150 patients with early pregnancy threatened miscarriage were enrolled for this study. Of the patients studied, 105 (70%) had a viable pregnancy and 45 (30%) had non-viable pregnancies. The mean serum progesterone was higher in the viable pregnancy, 17.97 ± 7.75 ng/ml, compared to non-viable group, 6.21 ± 2.86 ng/ml. The area under curve was calculated, and a cut-off value of 10.08 ng/ml was obtained. 83.8% of viable pregnancies had serum progesterone more than or equal to 10.08 ng/ml which was statistically significant.

CONCLUSION

A single value of progesterone is useful in predicting the viability of the ongoing threatened pregnancy. Serum progesterone with a cut-off value of 10.8 ng/ml was found to have a positive predictive value of 95.7% and negative predictive value of 70.7% with an accuracy of 86%.

Pregnancy of unknown location: Evaluation and management

Early diagnosis of an extrauterine pregnancy is important for safe and effective management. However, a pregnancy's location often cannot be easily determined with abnormal implantations or prior to 5-6 weeks' gestation. Multiple testing strategies exist to diagnose an abnormal pregnancy when location is unknown, but caution needs to be used to avoid a false diagnosis. Medical treatment is optimal when an abnormal pregnancy is diagnosed early. Because most of these pregnancies are intrauterine, additional testing to localize the pregnancy will allow the correct choice of therapy and avoids unnecessary exposure to a toxic therapy. This testing strategy should be reserved for patients with significant concern for ectopic pregnancy, based on either risk factors or clinical findings. Overuse of this approach can lead to interruption of normal pregnancies.

hCG production by mucinous adenocarcinoma of the ovary in a reproductive aged woman

When elevated serum hCG is discovered during the work up of a gynecologic tumor, it is paramount to identify the source of hCG prior to initiation of treatment. Potential sources of hCG include viable intrauterine pregnancy, ectopic pregnancy, miscarriage, gestational trophoblastic disease, pituitary hCG production, phantom hCG (heterophilic antibody interference), and tumor production. Here, we present a case of elevated hCG in a young women with a large complex pelvic mass. Prior to treatment initiation, the patient underwent work up for hCG elevation, which was ultimately found to be from tumor production. Pathologic examination revealed the mass to be a mucinous adenocarcinoma of the ovary with aberrant expression of hCG, rather than the more typical hCG producing germ cell tumor. We detail the preoperative evaluation process of hCG elevation. Additionally, we discuss the role of hCG in ovarian cancer and influence on tumorigenesis and management.

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Evaluation of elevated hCG in a premenopausal patient is complex but necessary prior to surgical intervention.

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Abberant hCG production resulting in elevated serum hCG can be seen in mucinous adenocarcinomas of the ovary.

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hCG production in ovarian cancer may be a useful marker for surveillance.

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.

The randomised controlled trial of micronised progesterone and dydrogesterone (TRoMaD) for threatened miscarriage

There has not been conclusive evidence in literature on the efficacy of progestogen in the treatment of threatened miscarriage, although some studies showed benefits. In our centre, threatened miscarriage is treated with either micronised progesterone (MP) or dydrogesterone (DYD).

OBJECTIVE

The aim of this study is to compare clinical outcomes of miscarriage, extent of vaginal bleeding at follow-up and side effects between treatment groups.

STUDY DESIGN

This study was a prospective parallel-group, open-label, randomized controlled trial. 141 women presenting with threatened miscarriage were randomised to either MP or DYD of which 118 were included in the analysis. Baseline maternal demographics and serum progesterone levels were collected at presentation. Post-treatment bleeding pattern and self-reported side effects were recorded at the follow-up visit (on day 4-10 of treatment). The occurrence of spontaneous miscarriage was ascertained at week 16 of gestation.

RESULTS

The population with miscarriage and resolution of bleeding were not statistically different between MP and DYD groups. A significantly higher percentage of women treated with MP reported drowsiness (p = 0.003). After stratification into low and high serum progesterone levels, a significantly higher miscarriage rate was found in the low progesterone group, regardless of treatment type.

CONCLUSION

In conclusion, extent of bleeding at day 4-10 and subsequent miscarriage rates were comparable between MP and DYD groups. However, fewer patients treated with DYD reported drowsiness and giddiness. The finding of significantly higher miscarriage rates in women with low progesterone levels despite treatment is an important factor to consider in counselling and prognosticating pregnancy outcomes.

The potential value of activin B and fibronectin for the triage of pregnancies of unknown location and prediction of first trimester viability

Aim

We have assessed the potential predictive ability of the biomarkers activin B and fibronectin (FN1) alone and when added to established markers for triaging patients as being at low or high risk of ectopic pregnancy (EP). We also assessed their use as predictors of viability at 12 weeks gestation.

Methods

Exploratory secondary analysis of a prospective study including all women classified as a pregnancy of known location (PUL) based on transvaginal ultrasonography between January and December 2007 at the early pregnancy unit of St Georges' Hospital (London). We used multinomial logistic regression to assess the diagnostic potential of the biomarkers to triage PUL at high risk of complications (EP or persistent PUL), and standard binary logistic regression to predict first trimester viability at 12 weeks.

Results

For discriminating high-risk (n = 16) from low-risk PUL (n = 93), the area under the receiver operating characteristic curve (AUC) was 0.75 (95% confidence interval 0.60-0.85) for activin B and 0.55 (0.41-0.68) for FN1. Adding activin B to a multinomial logistic regression model incorporating β-hCG ratio and initial progesterone yielded odds ratios of 0.16 (0.05-0.55) for failing vs high-risk PUL and 0.29 (0.07-1.19) for intrauterine vs high-risk PUL and increased the model's AUC from 0.84 to 0.89. At a risk threshold of 5% for high-risk PUL, sensitivity increased from 84% to 87% and specificity from 48% to 64%. For discriminating viable (n = 28) from non-viable (n = 81) pregnancies at 12 weeks, both markers had an AUC of 0.54.

Conclusions

Our results suggested that activin B may be a promising marker to improve PUL triage in addition to established markers.

Emergency Medicine Myths: Ectopic Pregnancy Evaluation, Risk Factors, and Presentation

BACKGROUND

Ectopic pregnancy (EP) is an important cause of morbidity and mortality in females of reproductive age. Proper diagnosis and treatment are critical, as complications such as rupture, hemorrhagic shock, and even death can occur.

OBJECTIVE

EP is a condition emergency physicians are trained to detect, yet there are multiple myths concerning its evaluation and diagnosis. This article reviews several of these myths in order to improve emergency department (ED) evaluation and diagnosis.

DISCUSSION

EP is a difficult diagnosis and may be missed on initial ED visit. While the diagnosis is often delayed simply due to very early presentations, it can also be missed because patients may not have all the same risk factors or demonstrate the same symptoms. They may also not demonstrate the same serum B-human chorionic gonadotropin levels and trends or have the same ultrasound findings at equivalent gestational ages. Some patients with early EP may have positive ultrasound findings with serum β-hCG levels under a defined discriminatory zone (DZ). On the other hand, some patients with an early viable intrauterine pregnancy may have no visible findings on initial ultrasound, but have serum β-hCG (quantitative) levels well above the DZ. Although rare, EP has even been demonstrated in women with negative urine β-hCG tests or low serum β-hCG levels.

CONCLUSIONS

While EP may be a challenging diagnosis, understanding the myths surrounding EP may help emergency physicians consider it, even when patient risk factors, symptoms, or ED laboratory or imaging studies do not initially or easily define the diagnosis.

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.

Progesterone in normal and pathological pregnancy

Progesterone is an essential hormone in the process of reproduction. It is involved in the menstrual cycle, implantation and is essential for pregnancy maintenance. It has been proposed and extensively used in the treatment of different gynecological pathologies as well as in assisted reproductive technologies and in the maintenance of pregnancy. Called "the pregnancy hormone", natural progesterone is essential before pregnancy and has a crucial role in its maintenance based on different mechanisms such as: modulation of maternal immune response and suppression of inflammatory response (the presence of progesterone and its interaction with progesterone receptors at the decidua level appears to play a major role in the maternal defense strategy), reduction of uterine contractility (adequate progesterone concentrations in myometrium are able to counteract prostaglandin stimulatory activity as well as oxytocin), improvement of utero-placental circulation and luteal phase support (it has been demonstrated that progesterone may promote the invasion of extravillous trophoblasts to the decidua by inhibiting apoptosis of extravillous trophoblasts). Once the therapeutic need of progesterone is established, the key factor is the decision of the best route to administer the hormone and the optimal dosage determination. Progesterone can be administered by many different routes, but the most utilized are oral, the vaginal and intramuscular administration. The main uses of progesterone are represented by: threatened miscarriage, recurrent miscarriage and preterm birth (in the prevention strategy, as a tocolytic agent and also in the maintenance of uterine quiescence).

Serum progesterone trend after day of transfer predicts live birth in fresh IVF cycles

PURPOSE

Our objective was to determine if a change in serum P4 from day of transfer (defined as day 19) to day 28 could predict live birth outcome in patients undergoing IVF.

METHODS

This study was a retrospective analysis of fresh IVF cycles from 2010 to 2013 at a single center. Primary outcomes include raw and percent change in serum P4, live birth rate, missed abortion, and biochemical pregnancies.

RESULTS

Our results showed an association between live birth rate and percent change in P4. Patients with a 10% or greater drop in serum P4 from day 19 to day 28 had a lower live birth rate, at 26 versus 63%. Interestingly, both groups had "normal" serum P4 levels on day 19, but patients with a 10% or greater drop had lower P4 levels than their counterparts. There was no association between percent P4 change and spontaneous abortion or biochemical pregnancy.

CONCLUSIONS

This is the first study to show that percent drop in serum P4 from day of transfer to day 28 is associated with decreased rates of live birth and ongoing pregnancy in fresh IVF cycles, even despite "high or normal" P4 levels on day of transfer.

Early pregnancy angiogenic markers and spontaneous abortion: an Odense Child Cohort study

BACKGROUND

Spontaneous abortion is the most commonly observed adverse pregnancy outcome. The angiogenic factors soluble Fms-like kinase 1 and placental growth factor are critical for normal pregnancy and may be associated to spontaneous abortion.

OBJECTIVE

We investigated the association between maternal serum concentrations of soluble Fms-like kinase 1 and placental growth factor, and subsequent spontaneous abortion.

STUDY DESIGN

In the prospective observational Odense Child Cohort, 1676 pregnant women donated serum in early pregnancy, gestational week <22 (median 83 days of gestation, interquartile range 71-103). Concentrations of soluble Fms-like kinase 1 and placental growth factor were determined with novel automated assays. Spontaneous abortion was defined as complete or incomplete spontaneous abortion, missed abortion, or blighted ovum <22+0 gestational weeks, and the prevalence was 3.52% (59 cases). The time-dependent effect of maternal serum concentrations of soluble Fms-like kinase 1 and placental growth factor on subsequent late first-trimester or second-trimester spontaneous abortion (n = 59) was evaluated using a Cox proportional hazards regression model, adjusting for body mass index, parity, season of blood sampling, and age. Furthermore, receiver operating characteristics were employed to identify predictive values and optimal cut-off values.

RESULTS

In the adjusted Cox regression analysis, increasing continuous concentrations of both soluble Fms-like kinase 1 and placental growth factor were significantly associated with a decreased hazard ratio for spontaneous abortion: soluble Fms-like kinase 1, 0.996 (95% confidence interval, 0.995-0.997), and placental growth factor, 0.89 (95% confidence interval, 0.86-0.93). When analyzed by receiver operating characteristic cut-offs, women with soluble Fms-like kinase 1 <742 pg/mL had an odds ratio for spontaneous abortion of 12.1 (95% confidence interval, 6.64-22.2), positive predictive value of 11.70%, negative predictive value of 98.90%, positive likelihood ratio of 3.64 (3.07-4.32), and negative likelihood ratio of 0.30 (0.19-0.48). For placental growth factor <19.7 pg/mL, odds ratio was 13.2 (7.09-24.4), positive predictive value was 11.80%, negative predictive value was 99.0%, positive likelihood ratio was 3.68 (3.12-4.34), and negative likelihood ratio was 0.28 (0.17-0.45). In the sensitivity analysis of 54 spontaneous abortions matched 1:4 to controls on gestational age at blood sampling, the highest area under the curve was seen for soluble Fms-like kinase 1 in prediction of first-trimester spontaneous abortion, 0.898 (0.834-0.962), and at the optimum cut-off of 725 pg/mL, negative predictive value was 51.4%, positive predictive value was 94.6%, positive likelihood ratio was 4.04 (2.57-6.35), and negative likelihood ratio was 0.22 (0.09-0.54).

CONCLUSION

A strong, novel prospective association was identified between lower concentrations of soluble Fms-like kinase 1 and placental growth factor measured in early pregnancy and spontaneous abortion. A soluble Fms-like kinase 1 cut-off <742 pg/mL in maternal serum was optimal to stratify women at high vs low risk of spontaneous abortion. The cause and effect of angiogenic factor alterations in spontaneous abortions remain to be elucidated.

Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy

Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.

Role of serum biomarkers in the prediction of outcome in women with threatened miscarriage: a systematic review and diagnostic accuracy meta-analysis

BACKGROUND

Threatened miscarriage affects one in five women and is associated with significant emotional distress. The uncertainty around the prognosis of threatened miscarriage makes it equally challenging to the healthcare professionals. Various biochemical markers have been investigated in the past to predict the outcome of threatened miscarriage; however, the results have been conflicting. Therefore, we have conducted a systematic review and meta-analysis to determine the diagnostic accuracy of biochemical markers in predicting the outcome in women presenting with threatened miscarriage.

METHODS

This is a systematic review and meta-analysis of prospective studies that investigated biochemical markers to determine outcomes for women with threatened miscarriage at 5-23 weeks gestational age. Electronic databases were searched up to June 2015 and study quality assessment was performed using QUADAS-2 (Quality Assessment for Diagnostic Accuracy Studies-2: A Revised Tool) for evaluating the diagnostic accuracy studies. Statistical analysis was performed using the Cochrane systematic review software.

RESULTS

A total of 19 studies were included in the qualitative data synthesis of which 15 (including 1263 women) were eligible for the meta-analysis. The review highlights the role of biochemical markers serum progesterone, hCG, pregnancy associated plasma protein A, estradiol and cancer antigen 125 (CA 125) in the prediction of outcome in women with threatened miscarriage. Interestingly, serum CA 125 appears to be the most promising marker (n = 648 women in seven studies), whereas serum progesterone and hCG are less useful once fetal viability is established. The summary receiver operating characteristics for CA 125 showed a sensitivity of 90% (95% confidence interval (CI) 83-94%), specificity of 88% (95% CI 79-93%), positive likelihood ratio of 7.86 (95% CI 4.23-14.60) and negative likelihood ratio of 0.10 (95% CI 0.06-0.20). The inverse of negative likelihood ratio was 9.31 (95% CI 5-17.1) indicating that a negative test is likely to identify those who are likely to continue with the pregnancy. Serum estradiol was the next best marker with a sensitivity of 45% (95% CI 6-90%), a specificity of 87% (95% CI 81-92%), a positive likelihood ratio of 3.72 (95% CI 1.01-13.71) and a negative likelihood ratio of 0.62 (95% CI 0.20-1.84).

CONCLUSIONS

In women with threatened miscarriage, serum CA 125 has high predictive value in identifying pregnancies that are 'likely to continue', whereas the most commonly used biomarkers of serum hCG and progesterone are not useful in predicting outcome of a pregnancy with a viable fetus. Other markers such as inhibin A and a combination of markers need to be investigated to hopefully improve the prediction of outcome in women with threatened miscarriage.

Problems of modern approaches to management of early pregnancy failure

In the last 20 to 30 years, early diagnosis of pregnancy has markedly decreased ectopic pregnancy-related maternal mortality, and the necessity for surgical treatment. With modern approaches in the treatment of ectopic pregnancy, surgical therapy has been replaced by medical therapy and medical treatment by spontaneous follow-up in appropriate cases. However, this current trend has led to some problems, including the maximization of ultrasonographic interpretations, misunderstandings in serial human koryonik gonadotropin hormon measurements, and complications due to inappropriate methotrexate use. The aim of the present study was to review the literature relating to the diagnosis and follow-up of early pregnancies, to underline some of the important considerations, and to help avoid possible iatrogenic errors.