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Iqbal M, Zubair M, Saeed Awan A, Khan Y, Yasmin H, Rahim R, Srichand P, Pal SA, Mazhar SB, Sohail R, Zaman F, Ali S, Ali T. Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach. Cureus 2024; 16:e65079. [PMID: 39171060 PMCID: PMC11337146 DOI: 10.7759/cureus.65079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVE It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan. METHODS A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus. RESULTS Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion. CONCLUSION These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.
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Affiliation(s)
- Maryam Iqbal
- Obstetrics and Gynecology, Integrated Medical Care Hospital, Lahore, PAK
| | - Maryam Zubair
- Obstetrics and Gynecology, Azad Jammu Kashmir Medical College, Muzaffarabad, PAK
| | - Azra Saeed Awan
- Obstetrics and Gynecology, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Yousaf Khan
- Obstetrics and Gynecology, Hameed Latif Hospital, Lahore, PAK
| | - Haleema Yasmin
- Obstetrics and Gynecology, Jinnah Postgraduate Medical Center (JPMC), Karachi, PAK
| | - Rehana Rahim
- Obstetrics and Gynecology, Lady Ready Hospital, Peshawar, PAK
| | - Pushpa Srichand
- Obstetrics and Gynecology, Isra University Hospital, Hyderabad, PAK
| | - Sadiah A Pal
- Epidemiology, Concept Fertility Center, Karachi, PAK
| | - Syeda Batool Mazhar
- Obstetrics and Gynecology, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Rubina Sohail
- Epidemiology and Public Health, Hameed Latif Hospital, Lahore, PAK
| | - Farrukh Zaman
- Obstetrics and Gynecology, Hameed Latif Hospital, Lahore, PAK
| | - Sobia Ali
- Medical Affairs, Established Pharmaceutical Division, Abbott Laboratories (Pakistan) Limited, Karachi, PAK
| | - Tabrez Ali
- Medical Affairs, Established Pharmaceutical Division, Abbott Laboratories (Pakistan) Limited, Karachi, PAK
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Ryu S, Lee CM, Kang BK, Kim M. Retroperitoneal Ectopic Pregnancy Detected by CT: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:217-221. [PMID: 38362382 PMCID: PMC10864160 DOI: 10.3348/jksr.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/31/2023] [Accepted: 08/26/2023] [Indexed: 02/17/2024]
Abstract
Retroperitoneal ectopic pregnancy is a rare form of ectopic pregnancy. Owing to its rarity and nonspecific symptoms, diagnosing retroperitoneal ectopic pregnancy at the initial presentation poses a significant challenge. Typically, the diagnosis relies on non-radiation imaging modalities, such as ultrasonography and MRI, whereas CT is infrequently used. Herein, we report a rare case of a retroperitoneal ectopic pregnancy, which was diagnosed using CT.
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Bonito G, Masselli G, Gigli S, Ricci P. Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications. Diagnostics (Basel) 2023; 13:2890. [PMID: 37761257 PMCID: PMC10528445 DOI: 10.3390/diagnostics13182890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.
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Affiliation(s)
- Giacomo Bonito
- Department of Emergency Radiology, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.B.); (P.R.)
| | - Gabriele Masselli
- Department of Emergency Radiology, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.B.); (P.R.)
| | - Silvia Gigli
- Department of Diagnostic Imaging, Sandro Pertini Hospital, Via dei Monti Tiburtini 385, 00157 Rome, Italy;
| | - Paolo Ricci
- Department of Emergency Radiology, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.B.); (P.R.)
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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4
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Ning N, Luo D, Xia W, Mou G, Zhao J, Zhang J, Li C, Wang H, Li J. Dysregulation of TMEM16A impairs oviductal transport of embryos. Am J Physiol Cell Physiol 2023; 325:C623-C632. [PMID: 37458439 DOI: 10.1152/ajpcell.00031.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 08/25/2023]
Abstract
Ectopic pregnancy is an acute abdominalgia in obstetrics and gynecology, especially in fallopian tubal pregnancy. The ion channel protein transmembrane protein 16A (TMEM16A) is widely distributed in various tissues, even in the oviduct. In this study, we showed that TMEM16A was expressed in the human fallopian tube and was upregulated in patients with tubal pregnancy. By measuring isolated fallopian tube tissues, we found that TMEM16A was involved in regulating not only the contraction of muscle strips but also the beat frequency of cilia. In addition, pharmacological activation or inhibition of TMEM16A could lead to retention of embryos in oviducts. Moreover, the embryos in oviducts were delayed in development and some of them had malformations and deletions. The total number of embryos in the oviducts and uterus was significantly less than that of the control group. Furthermore, we detected changes in the level of m6A methylation, where the relevant writers and readers were reduced in tubal tissues from tubal pregnancies. In m6A mRNA methylation, writers catalyze the addition of methyl groups to cytosine residues and readers bind to the methyl groups and affect gene translation. In human fallopian tube epithelial cell line FTE187, we found that interference with methyltransferase 3 (METTL3) expression increased TMEM16A, suggesting that TMEM16A might be regulated by m6A methylation. In general, our study revealed a novel regulatory point for embryo transport and development, introducing a new role for the diagnosis and treatment of tubal pregnancy.NEW & NOTEWORTHY The ion channel protein TMEM16A is expressed in the epithelium and smooth muscle of the human fallopian tube and is upregulated in patients with tubal pregnancy. TMEM16A is involved in regulating the smooth muscle contraction and the cilia beating. Dysregulated TMEM16A may result in embryo retention in the oviduct and delayed early embryo development. Our study reveals a new regulatory point for embryo transport and development.
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Affiliation(s)
- Nannan Ning
- Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, People's Republic of China
- Shandong Engineering Research Center of Biomarker and Artificial Intelligence Application, Jinan, People's Republic of China
| | - Dan Luo
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
- Shanghai Key Laboratory Embryo Original Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Guangjing Mou
- Department of Physiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Jiangli Zhao
- Department of Physiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Cheng Li
- Obstetrics and Gynecology Hospital, Institute of Reproduction and Development, Fudan University, Shanghai, People's Republic of China
| | - Hongchun Wang
- Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, People's Republic of China
- Shandong Engineering Research Center of Biomarker and Artificial Intelligence Application, Jinan, People's Republic of China
| | - Jingxin Li
- Department of Physiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
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Moses AS, Kadam L, St Lorenz A, Baldwin MK, Morgan T, Hebert J, Park Y, Lee H, Demessie AA, Korzun T, Mamnoon B, Alani AWG, Taratula O, Myatt L, Taratula OR. Nano-Theranostic Modality for Visualization of the Placenta and Photo-Hyperthermia for Potential Management of Ectopic Pregnancy. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2023; 19:e2202343. [PMID: 36394151 PMCID: PMC9839489 DOI: 10.1002/smll.202202343] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/26/2022] [Indexed: 05/03/2023]
Abstract
Ectopic pregnancy (EP) is the leading cause of maternity-related death in the first trimester of pregnancy. Approximately 98% of ectopic implantations occur in the fallopian tube, and expedient management is crucial for preventing hemorrhage and maternal death in the event of tubal rupture. Current ultrasound strategies misdiagnose EP in up to 40% of cases, and the failure rate of methotrexate treatment for confirmed EP exceeds 10%. Here the first theranostic strategy for potential management of EP is reported using a near-infrared naphthalocyanine dye encapsulated within polymeric nanoparticles. These nanoparticles preferentially accumulate in the developing murine placenta within 24 h following systemic administration, and enable visualization of implantation sites at various gestational stages via fluorescence and photoacoustic imaging. These nanoparticles do not traverse the placental barrier to the fetus or impact fetal development. However, excitation of nanoparticles localized in specific placentas with focused NIR light generates heat (>43 °C) sufficient for disruption of placental function, resulting in the demise of targeted fetuses with no effect on adjacent fetuses. This novel approach would enable diagnostic confirmation of EP when current imaging strategies are unsuccessful, and elimination of EP could subsequently be achieved using the same nano-agent to generate localized hyperthermia resulting in targeted placental impairment.
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Affiliation(s)
- Abraham S Moses
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Leena Kadam
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anna St Lorenz
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Maureen K Baldwin
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Terry Morgan
- Department of Pathology and Laboratory Medicine, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Jessica Hebert
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Youngrong Park
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Hyelim Lee
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Ananiya A Demessie
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Tetiana Korzun
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Babak Mamnoon
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Adam W G Alani
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Oleh Taratula
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
| | - Leslie Myatt
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Olena R Taratula
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, 2730 S Moody Avenue, Portland, OR, 97201, USA
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Iv Kyrazis C, Rajderkar D. A Pictorial Review of Pelvic Pain-Beyond the Genitourinary System. Ultrasound Q 2022; 38:304-315. [PMID: 36194672 DOI: 10.1097/ruq.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ABSTRACT Pelvic pain may be caused by disorders of the reproductive, urinary, or gastrointestinal systems. In the pediatric population, pelvic pain is often first evaluated with ultrasonography, with other imaging modalities reserved for further workup or specific indications. Radiologists must be aware of the findings associated with common pelvic emergencies to allow prompt diagnosis and prevention of life-threatening complications. Although the range of pelvic pathology is extensive, this pictorial review presents ultrasound examples of common nontraumatic causes of pelvic pain encountered in the pediatric population, with a brief discussion about multimodality imaging features.
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Affiliation(s)
| | - Dhanashree Rajderkar
- Department of Radiology, Division of Pediatric Radiology, University of Florida, Gainesville, FL
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7
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Ren F, Liu G, Wang T, Li M, Guo Z. Unruptured ovarian ectopic pregnancy: Two case reports and literature review. Front Physiol 2022; 13:1036365. [PMID: 36388130 PMCID: PMC9641050 DOI: 10.3389/fphys.2022.1036365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/05/2022] [Indexed: 11/26/2022] Open
Abstract
In clinical practice, ovarian pregnancy is extremely rare and is always found to be ruptured. A definitive diagnosis for ruptured ovarian pregnancy is difficult to obtain. We present two cases of unruptured ovarian pregnancies detected during laparoscopy and review existing literature to better understand the clinical characteristics of ectopic pregnancies in this rare site. Intrauterine devices, assisted reproductive technology, and intrauterine operations are all high-risk factors in ovarian pregnancy. Moreover, menopause, abdominal pain, and vaginal bleeding are clinical manifestations. Ovarian pregnancy can be diagnosed using serum hCG, transvaginal ultrasound, and magnetic resonance imaging. Laparoscopy is the treatment of choice for ovarian pregnancy. It is recommended that the intact gestational sac be excised and the ovarian function be protected to the greatest extent possible during the operation. More definitive diagnosis of ovarian pregnancy must be reported in order to gain a better understanding of ovarian pregnancy.
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Affiliation(s)
- Fang Ren
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Gang Liu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tifang Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meijun Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhiqiang Guo
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Zhiqiang Guo,
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8
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Imaging of complications following treatment with assisted reproductive technology: keep on your radar at each step. Abdom Radiol (NY) 2022; 47:328-340. [PMID: 34535828 DOI: 10.1007/s00261-021-03245-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/07/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
Since the advent of assisted reproductive technology (ART), the utilization of ART procedures has become increasingly popular among women seeking to establish pregnancy. Radiologists are therefore likely to encounter the various complications of ART therapy. The most common is ovarian hyperstimulation syndrome; others are multiple, ectopic, and heterotopic pregnancies. Ultrasonography is considered the initial modality to investigate ART complications, However, nonspecific symptoms might need the use of an additional imaging modality, such as computed tomography or magnetic resonance imaging, as a problem-solving tool. This article briefly discusses the steps involved in assisted reproduction. Its aim is to help radiologists become familiarized with the multimodality imaging features of the spectrum of ART-related complications. Their key imaging features and differential considerations are emphasized. This will facilitate the provision of precise and timely diagnoses, and aid the avoidance of fatal consequences.
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9
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Ectopic pregnancy: a resident's guide to imaging findings and diagnostic pitfalls. Emerg Radiol 2021; 29:161-172. [PMID: 34618256 DOI: 10.1007/s10140-021-01974-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.
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10
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Singh S, Rout PK, Ayyanar P. Catch Me While You Scan: Primary Ovarian Pregnancy. J Hum Reprod Sci 2021; 14:200-202. [PMID: 34316238 PMCID: PMC8279051 DOI: 10.4103/jhrs.jhrs_50_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/04/2020] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
Primary ovarian pregnancy is rare, accounting for 0.5%–3.0% of all ectopic gestations. It was earlier diagnosed by the classical Spiegelberg's criteria. Ultrasonographic diagnostic criteria have now been described for preoperative diagnosis. We report a case of primary ovarian pregnancy in a 30-year-old woman, where the diagnosis was made preoperatively, and discuss the challenges in diagnosis and management for optimal patient outcomes.
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Affiliation(s)
- Sweta Singh
- Department of Obstetrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Prashanta Kumar Rout
- Department of Obstetrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Pavithra Ayyanar
- Department of Pathology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Mosconi C, Crocetti L, Bruno A, Candita G, Cappelli A, Perrone O, Golfieri R, Cioni R. Scar Pregnancy and Extrauterine Implants. Semin Ultrasound CT MR 2021; 42:46-55. [PMID: 33541589 DOI: 10.1053/j.sult.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cesarean scar pregnancy (CSP) is a rare occurrence consisting in the implantation of the embryo within the myometrium of a prior cesarean delivery scar. The CSP could be a dangerous condition for women because of the related complications such as placenta previa or accreta, uterine rupture, and hemorrhage. Therefore, early diagnosis and rapid treatment are crucial. Extrauterine implants or ectopic pregnancy (EP) consists in the implantation of an embryo in a site other than the endometrium of the uterine cavity. It occurs in 1%-2% of all reported pregnancies. The most common extrauterine location is the fallopian tube, which represents 96% of cases. The diagnosis of CSP and EP is based on history, clinical examination, levels of serum β-human chorionic gonadotropin (β-hCG), and ultrasonography findings. In last 20 years, new treatments were developed, varying from medical management, minimally invasive surgical approach and local treatment including systemic or local infusion of metotrexate (MTX), and uterine artery embolization (UAE). UAE has been used widely to control hemorrhage and preserve the uterus and it is considered an affective adjuvant treatment of CSP and EP, especially associated with other therapies.
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Affiliation(s)
- Cristina Mosconi
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Laura Crocetti
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Antonio Bruno
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Gianvito Candita
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alberta Cappelli
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Orsola Perrone
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Roberto Cioni
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Garikapati K, Gogineni S, Prasuna NL, Eda V. Ectopic pregnancy: “THE MASQUERADER” -A challenge to medical fraternity. JOURNAL OF DR. NTR UNIVERSITY OF HEALTH SCIENCES 2021. [DOI: 10.4103/jdrntruhs.jdrntruhs_45_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Istrate-Ofiţeru AM, Ruican D, Niculescu M, Nagy RD, Roşu GC, Petrescu AM, Drăguşin RC, Iovan L, Zorilă GL, Iliescu DG. Ovarian ectopic pregnancy: the role of complex morphopathological assay. Review and case presentation. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2020; 61:985-997. [PMID: 34171048 PMCID: PMC8343605 DOI: 10.47162/rjme.61.4.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/27/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Anca-Maria Istrate-Ofiţeru
- Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
- Research Center for Microscopic Morphology and Immunology, University of Medicine and Pharmacy of Craiova, Romania
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
| | - Dan Ruican
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
- PhD Student, Doctoral School, University of Medicine and Pharmacy of Craiova, Romania
| | - Mihaela Niculescu
- Department of Anatomy, University of Medicine and Pharmacy of Craiova, Romania
| | - Rodica Daniela Nagy
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
- PhD Student, Doctoral School, University of Medicine and Pharmacy of Craiova, Romania
| | - Gabriela-Camelia Roşu
- Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
- Research Center for Microscopic Morphology and Immunology, University of Medicine and Pharmacy of Craiova, Romania
| | - Ana-Maria Petrescu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
| | - Roxana Cristina Drăguşin
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
| | - Larisa Iovan
- Department of Histology, University of Medicine and Pharmacy of Craiova, Romania
- Research Center for Microscopic Morphology and Immunology, University of Medicine and Pharmacy of Craiova, Romania
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
- PhD Student, Doctoral School, University of Medicine and Pharmacy of Craiova, Romania
| | - George Lucian Zorilă
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
| | - Dominic Gabriel Iliescu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Romania
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Abstract
BACKGROUND Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP). OBJECTIVES To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data. SELECTION CRITERIA We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy. DATA COLLECTION AND ANALYSIS We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications. MAIN RESULTS We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar. AUTHORS' CONCLUSIONS For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.
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Affiliation(s)
- Ying Long
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Huili Zhu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuanyuan Hu
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Licong Shen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jing Fu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
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Santos LTR, Oliveira SCDS, Rocha LGA, Sousa NDS, Figueiredo RDS. Interstitial Pregnancy: Case Report of Atypical Ectopic Pregnancy. Cureus 2020; 12:e8081. [PMID: 32542136 PMCID: PMC7292689 DOI: 10.7759/cureus.8081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
Interstitial or cornual implantation of the blastocyst is rare, accounting for 2% to 3% of ectopic pregnancies, being considered not viable. The important complications of interstitial pregnancy are uterine rupture and massive bleeding, which usually occur before 12 weeks of pregnancy. The authors report a case of a 36-year-old woman with complaints of transvaginal bleeding and abdominal pain associated with amenorrhea for seven weeks and positive beta-human chorionic gonadotropin (HCG). Transvaginal ultrasound and exploratory laparotomy were performed, confirming the diagnosis of interstitial ectopic pregnancy. The patient underwent a salpingectomy and cornual resection on the left, evolving with clinical improvement and hospital discharge.
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Affiliation(s)
| | | | | | | | - Rosenildo de Sousa Figueiredo
- Obstetrics and Gynecology, Santa Casa de Misericórdia Hospital, Sobral, BRA
- Obstetrics and Gynecology, Sao Camilo Hospital, Tiangua, BRA
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16
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Tran-Harding K, Lee JT, Owen J. Recognizing the CT Manifestations of Gynecologic Conditions Encountered in the Emergency Department. Curr Probl Diagn Radiol 2019; 48:473-481. [DOI: 10.1067/j.cpradiol.2018.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/02/2018] [Accepted: 07/17/2018] [Indexed: 11/22/2022]
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17
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Hirshberg B, Rheinboldt M. Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction. Emerg Radiol 2019; 26:205-219. [PMID: 30631995 DOI: 10.1007/s10140-018-01665-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/13/2018] [Indexed: 02/02/2023]
Abstract
Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.
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18
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Brown DL, Packard A, Maturen KE, Deshmukh SP, Dudiak KM, Henrichsen TL, Meyer BJ, Poder L, Sadowski EA, Shipp TD, Simpson L, Weber TM, Zelop CM, Glanc P. ACR Appropriateness Criteria ® First Trimester Vaginal Bleeding. J Am Coll Radiol 2018; 15:S69-S77. [DOI: 10.1016/j.jacr.2018.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/27/2022]
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19
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To evaluate the feasibility of magnetic resonance imaging in predicting unusual site ectopic pregnancy: a retrospective cohort study. Eur Radiol 2018; 28:2444-2454. [PMID: 29349699 DOI: 10.1007/s00330-017-5237-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the accuracy of pelvic MRI in the diagnosis of unusual ectopic pregnancy (EP), when ultrasound (US) examination is inconclusive. METHODS We retrospectively reviewed the medical records of 150 patients with suspected EP. Clinical, US and MRI features of 15 unusual EPs were analysed. Two radiologists independently reviewed each case resolving by consensus any diagnostic discrepancy. Interobserver agreement was assessed using the Cohen κ test. RESULTS MRI displayed a gestational sac-like structure surrounded by a thick wall in all cases. The thick wall displayed hyperintensity in 41 %, isointensity in 35 % and hypointensity in 24 % of cases on T1-weighted images. Diffusion- and fat saturation T1-weighted images were the most accurate sequences, as they enabled identification of 15/15 and 14/15 patients, respectively. Although US was false negative in detecting cervical and uterine infiltration underlying the caesarean scar, MRI was able to identify the invasion. Interobserver agreement was very good for all sequences (κ=0.892-1.0). CONCLUSIONS MRI plays an important role in the early diagnosis of unusual EP. It should be considered after negative US findings, providing accurate evaluation of the site and the possible infiltration of these lesions, which help in the management of these patients. KEY POINTS • MRI is being increasingly used as a problem-solving modality in ectopic pregnancy. • MRI plays an important role in early diagnosis of unusual ectopic pregnancy. • Knowledge of MRI features in EP is essential to determinate appropriate management.
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20
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Durur-Karakaya A, Seker M, Durur-Subasi İ. Diffusion-weighted imaging in ectopic pregnancy: ring of restriction sign. Br J Radiol 2017; 91:20170528. [PMID: 29023142 DOI: 10.1259/bjr.20170528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To demonstrate the diffusion-weighted imaging (DWI) findings of ectopic pregnancy (EP) and introduce the "ring of restriction" sign by discussing possible causes. METHODS Between January 2014 and January 2017, patients with EP and examined by MRI on a 3T scanner were retrospectively evaluated. MRI and DWI findings were recorded. RESULTS A total of 40 patients were diagnosed with EP at our university hospital, 8 of whom (20%) were evaluated by MRI and DWI. All of them were haemodynamically and clinically stable and could be imaged adequately. Locations were ovary (n = 3, 37.5%), tuba (n = 2, 25%), Caesarean section scar (n = 2, 25%) and parauterine (n = 1, 12.5%). In all eight EPs, the gestational sac diameter was compatible with 7-9 weeks. With DWI, the gestational sac was seen as a thick-walled cyst-like structure. The thick wall showed diffusion restrictions in all patients (ring of restriction sign). CONCLUSIONS DWI through its cellular and molecular evidence may contribute diagnosis of EP. Advances in knowledge: Being aware of the EP wall shows diffusion restriction (ring of restriction) avoids interpretation errors especially in appropriate clinical setting with no need for contrast material.
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Affiliation(s)
- Afak Durur-Karakaya
- 1 Department of Radiology, Faculty of Medicine, Istanbul Medipol University , Istanbul, Turkey
| | - Mehmet Seker
- 1 Department of Radiology, Faculty of Medicine, Istanbul Medipol University , Istanbul, Turkey
| | - İrmak Durur-Subasi
- 2 University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Clinic of Radiology , Ankara, Turkey xs
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Histed SN, Deshmukh M, Masamed R, Jude CM, Mohammad S, Patel MK. Ectopic Pregnancy: A Trainee's Guide to Making the Right Call: Women's Imaging. Radiographics 2017; 36:2236-2237. [PMID: 27831839 DOI: 10.1148/rg.2016160080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Stephanie N Histed
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Monica Deshmukh
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Rinat Masamed
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Cecilia M Jude
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Shaden Mohammad
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
| | - Maitraya K Patel
- From the Department of Radiologic Sciences, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095 (S.N.H., R.M., M.K.P.); and Department of Radiology, Olive View-UCLA Medical Center, Sylmar, Calif (M.D., C.M.J., S.M., M.K.P.)
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Lee R, Dupuis C, Chen B, Smith A, Kim YH. Diagnosing ectopic pregnancy in the emergency setting. Ultrasonography 2017; 37:78-87. [PMID: 29061036 PMCID: PMC5769947 DOI: 10.14366/usg.17044] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/14/2017] [Accepted: 08/19/2017] [Indexed: 11/03/2022] Open
Abstract
Ectopic pregnancy is the implantation of a fertilized egg outside the uterine endometrial cavity. For women presenting to the emergency department with abdominal pain and/or vaginal bleeding, ectopic pregnancy is an important diagnostic consideration. The diagnosis is made based on laboratory values and ultrasound imaging findings. The ultrasound appearance of both normal early pregnancy and ectopic pregnancy are variable and often subtle, presenting diagnostic challenges for radiologists. This pictorial essay describes and illustrates the sonographic findings of ectopic pregnancy and reviews the differential diagnoses that can mimic ectopic pregnancy on ultrasound. With the possibility of medical management, the value of early detection and prompt initiation of treatment has increased in improving clinical outcomes and preventing the complications of ectopic pregnancy.
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Affiliation(s)
- Robert Lee
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Carolyn Dupuis
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Byron Chen
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Andrew Smith
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Young H Kim
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
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23
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Srisajjakul S, Prapaisilp P, Bangchokdee S. Magnetic resonance imaging in tubal and non-tubal ectopic pregnancy. Eur J Radiol 2017; 93:76-89. [DOI: 10.1016/j.ejrad.2017.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/14/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
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A Case of Ruptured Interstitial Ectopic Pregnancy: Ultrasonographic Appearance With Gross Pathology Correlate. Ultrasound Q 2017; 33:181-183. [PMID: 28481765 DOI: 10.1097/ruq.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mausner Geffen E, Slywotzky C, Bennett G. Pitfalls and tips in the diagnosis of ectopic pregnancy. Abdom Radiol (NY) 2017; 42:1524-1542. [PMID: 28144719 DOI: 10.1007/s00261-016-1020-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound. In these situations, the primary role of pelvic ultrasound is to differentiate an ectopic pregnancy from either a normal or abnormal intrauterine pregnancy. While an accurately performed and interpreted pelvic ultrasound results in rapid diagnosis and management, numerous diagnostic pitfalls can lead to negative outcomes. Therefore, familiarity with the appropriate laboratory tests, sonographic technique, and imaging features of ectopic pregnancy is essential for all radiologists. We present a review of ectopic pregnancy cases from our institution with attention to common pitfalls and troubleshooting tips for physicians who perform and interpret pelvic ultrasounds. We also present recently published literature to aid in the management of first trimester pregnancy.
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Rivera Domínguez A, Mora Jurado A, García de la Oliva A, de Araujo Martins-Romeo D, Cueto Álvarez L. Gynecological pelvic pain as emergency pathology. RADIOLOGIA 2017. [DOI: 10.1016/j.rxeng.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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27
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Chanana C, Gupta N, Bansal I, Hooda K, Sharma P, Gupta M, Gandhi D, Kumar Y. Different Sonographic Faces of Ectopic Pregnancy. J Clin Imaging Sci 2017; 7:6. [PMID: 28299234 PMCID: PMC5341302 DOI: 10.4103/jcis.jcis_105_16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/31/2016] [Indexed: 11/04/2022] Open
Abstract
Vaginal bleeding in the first trimester has wide differential diagnoses, the most common being a normal early intrauterine pregnancy, with other potential causes including spontaneous abortion and ectopic pregnancy. The incidence of ectopic pregnancy is approximately 2% of all reported pregnancies and is one of the leading causes of maternal mortality worldwide. Clinical signs and symptoms of ectopic pregnancy are often nonspecific. History of pelvic pain with bleeding and positive β-human chorionic gonadotropin should raise the possibility of ectopic pregnancy. Knowledge of the different locations of ectopic pregnancy is of utmost importance, in which ultrasound imaging plays a crucial role. This pictorial essay depicts sonographic findings and essential pitfalls in diagnosing ectopic pregnancy.
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Affiliation(s)
- Charu Chanana
- Department of Obstetrics and Gynecological Surgery, Columbia University at Bassett Healthcare, Cooperstown, NY, USA
| | - Nishant Gupta
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Itisha Bansal
- Department of Anesthesiology, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Kusum Hooda
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, CT, USA
| | - Pranav Sharma
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, CT, USA
| | - Mohit Gupta
- Department of Radiology, Columbia University at Bassett Healthcare, Cooperstown, NY, USA
| | - Darshan Gandhi
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Yogesh Kumar
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, CT, USA
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Rivera Domínguez A, Mora Jurado A, García de la Oliva A, de Araujo Martins-Romeo D, Cueto Álvarez L. Gynecological pelvic pain as emergency pathology. RADIOLOGIA 2016; 59:115-127. [PMID: 27979433 DOI: 10.1016/j.rx.2016.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 09/19/2016] [Accepted: 09/30/2016] [Indexed: 11/17/2022]
Abstract
Acute pelvic pain is a common condition in emergency. The sources of acute pelvic pain are multifactorial, so it is important to be familiar with this type of pathologies. The purpose of this article is review the main causes of gynecological acute pelvic pain and their radiologic appearances to be able to make an accurate diagnosis and provide objective criteria for patient management.
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Affiliation(s)
- A Rivera Domínguez
- Unidad de Gestión Clínica de Radiodiagnóstico. Hospital Universitario Virgen Macarena, Sevilla, España.
| | - A Mora Jurado
- Unidad de Gestión Clínica de Radiodiagnóstico. Hospital Universitario Virgen Macarena, Sevilla, España
| | - A García de la Oliva
- Unidad de Gestión Clínica de Radiodiagnóstico. Hospital Universitario Virgen Macarena, Sevilla, España
| | - D de Araujo Martins-Romeo
- Unidad de Gestión Clínica de Radiodiagnóstico. Hospital Universitario Virgen Macarena, Sevilla, España
| | - L Cueto Álvarez
- Unidad de Gestión Clínica de Radiodiagnóstico. Hospital Universitario Virgen Macarena, Sevilla, España
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Imaging Unusual Pregnancy Implantations: Rare Ectopic Pregnancies and More. AJR Am J Roentgenol 2016; 207:1380-1392. [DOI: 10.2214/ajr.15.15290] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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30
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Bonde AA, Korngold EK, Foster BR, Fung AW, Sohaey R, Pettersson DR, Guimaraes AR, Coakley FV. Radiological appearances of corpus luteum cysts and their imaging mimics. Abdom Radiol (NY) 2016; 41:2270-2282. [PMID: 27472937 DOI: 10.1007/s00261-016-0780-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To review the radiological appearances of corpus luteum cysts and their imaging mimics. CONCLUSION Corpus luteum cysts are normal post-ovulatory structures seen in the ovaries through the second half of the menstrual cycle and the first trimester of pregnancy. The typical appearance, across all modalities, is of a 1- to 3-cm cyst with a thick crenulated vascularized wall. Occasionally, similar imaging findings may be seen with endometrioma, ectopic pregnancy, tuboovarian abscess, red degeneration of a fibroid, and ovarian neoplasia. In most cases, imaging findings are distinctive and allow for a confident and accurate diagnosis that provides reassurance for patients and referring physicians and avoids costly unnecessary follow-up.
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Pratilas GC, Chatzis P, Panteleris N, Chatzistamatiou K, Zeipiridis L, Dinas K. Concealed heterotopic pregnancy at 12 weeks, with no coexisting risk factors: Lessons to be learned. J Obstet Gynaecol Res 2016; 43:228-231. [DOI: 10.1111/jog.13157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 08/08/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Georgios C. Pratilas
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki; Ippokrateio Hospital of Thessaloniki; Thessaloniki Greece
| | - Panagiotis Chatzis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki; Ippokrateio Hospital of Thessaloniki; Thessaloniki Greece
| | - Nikolaos Panteleris
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki; Ippokrateio Hospital of Thessaloniki; Thessaloniki Greece
| | - Kimon Chatzistamatiou
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki; Ippokrateio Hospital of Thessaloniki; Thessaloniki Greece
| | - Leonidas Zeipiridis
- First Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki; Papageorgiou Hospital of Thessaloniki; Thessaloniki Greece
| | - Konstantinos Dinas
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki; Ippokrateio Hospital of Thessaloniki; Thessaloniki Greece
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Ohannessian A, Crochet P, Courbiere B, Gnisci A, Agostini A. Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2016; 44:341-344. [PMID: 27216957 DOI: 10.1016/j.gyobfe.2016.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/11/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART. METHODS A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time. RESULTS MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]). CONCLUSIONS It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.
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Affiliation(s)
- A Ohannessian
- Service de gynécologie-obstétrique, hôpital de La Conception, 147, boulevard Baille, 13005 Marseille, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de La Conception, 147, boulevard Baille, 13005 Marseille, France
| | - B Courbiere
- Service de gynécologie-obstétrique, hôpital de La Conception, 147, boulevard Baille, 13005 Marseille, France
| | - A Gnisci
- Service de gynécologie-obstétrique, hôpital de La Conception, 147, boulevard Baille, 13005 Marseille, France
| | - A Agostini
- Service de gynécologie-obstétrique, hôpital de La Conception, 147, boulevard Baille, 13005 Marseille, France.
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Dean HK, Hankin EJ. What Is Your Diagnosis? J Am Vet Med Assoc 2016; 248:1231-3. [PMID: 27172335 DOI: 10.2460/javma.248.11.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bobdiwala S, Guha S, Van Calster B, Ayim F, Mitchell-Jones N, Al-Memar M, Mitchell H, Stalder C, Bottomley C, Kothari A, Timmerman D, Bourne T. The clinical performance of the M4 decision support model to triage women with a pregnancy of unknown location as at low or high risk of complications. Hum Reprod 2016; 31:1425-35. [PMID: 27165655 DOI: 10.1093/humrep/dew105] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 04/07/2016] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What are the adverse outcomes associated with using the M4 model in everyday clinical practice for women with pregnancy of unknown location (PUL)? SUMMARY ANSWER There were 17/835 (2.0%) adverse events and no serious adverse events associated with the performance of the M4 model in clinical practice. WHAT IS KNOWN ALREADY The M4 model has previously been shown to stratify women classified as a PUL as at low or high risk of complications with a good level of test performance. The triage performance of the M4 model is better than single measurements of serum progesterone or the hCG ratio (serum hCG at 48 h/hCG at presentation). STUDY DESIGN, SIZE, DURATION A prospective multi-centre cohort study of 1022 women with a PUL carried out between August 2012 and December 2013 across 2 university teaching hospitals and 1 district general hospital. PARTICIPANTS/MATERIALS, SETTING, METHODS All women presenting with a PUL to the early pregnancy units of the three hospitals were recruited. The final outcome for PUL was either a failed PUL (FPUL), intrauterine pregnancy (IUP) or ectopic pregnancy (EP) (including persistent PUL (PPUL)), with EP and PPUL considered high-risk PUL. Their hCG results at 0 and 48 h were entered into the M4 model algorithm. If the risk of EP was ≥5%, the PUL was predicted to be high-risk and the participant was asked to re-attend 48 h later for a repeat hCG and transvaginal ultrasound scan by a senior clinician. If the PUL was classified as 'low risk, likely failed PUL', the participant was asked to perform a urinary pregnancy test 2 weeks later. If the PUL was classified as 'low risk, likely intrauterine', the participant was scheduled for a repeat scan in 1 week. Deviations from the management protocol were recorded as either an 'unscheduled visit (participant reason)', 'unscheduled visit (clinician reason)' or 'differences in timing (blood test/ultrasound)'. Adverse events were assessed using definitions outlined in the UK Good Clinical Practice Guidelines' document. MAIN RESULTS AND THE ROLE OF CHANCE A total of 835 (82%) women classified as a PUL were managed according to the M4 model (9 met the exclusion criteria, 69 were lost to follow-up, 109 had no hCG result at 48 h). Of these, 443 (53%) had a final outcome of FPUL, 298 (36%) an IUP and 94 (11%) an EP. The M4 model predicted 70% (585/835) PUL as low risk, of which 568 (97%) were confirmed as FPUL or IUP. Of the 17 EP and PPUL misclassified as low risk, 5 had expectant management, 7 medical management with methotrexate and 5 surgical intervention.Nineteen PUL had an unscheduled visit (participant reason), 38 PUL had an unscheduled visit (clinician reason) and 68 PUL had deviations from protocol due to a difference in timing (blood test/ultrasound).Adverse events were reported in 26 PUL and 1 participant had a serious adverse event. A total of 17/26 (65%) adverse events were misclassifications of a high risk PUL as low risk by the M4 model, while 5/26 (19%) adverse events were related to incorrect clinical decisions. Four of the 26 adverse events (15%) were secondary to unscheduled admissions for pain/bleeding. The serious adverse event was due to an incorrect clinical decision. LIMITATIONS, REASONS FOR CAUTION A limitation of the study was that 69/1022 (7%) of PUL were lost to follow-up. A 48 h hCG level was missing for 109/1022 (11%) participants. WIDER IMPLICATIONS OF THE FINDINGS The low number of adverse events (2.0%) suggests that expectant management of PUL using the M4 prediction model is safe. The model is an effective way of triaging women with a PUL as being at high- and low-risk of complications and rationalizing follow-up. The multi-centre design of the study is more likely to make the performance of the M4 model generalizable in other populations. STUDY FUNDING/COMPETING INTERESTS None. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- S Bobdiwala
- Tommy's National Early Miscarriage Research Centre, Queen Charlottes & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - S Guha
- Tommy's National Early Miscarriage Research Centre, Queen Charlottes & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK West Middlesex University Hospital, Twickenham Road, Isleworth, London TW7 6AF, UK
| | - B Van Calster
- Department of Development and Regeneration, KU Leuven, Herestraat 49 Box 7003, Leuven B-3000, Belgium
| | - F Ayim
- Hillingdon Hospital, Pield Heath Road, Uxbridge UB8 3NN, UK
| | - N Mitchell-Jones
- Chelsea & Westminster Hospital, 329 Fulham Road, London SW10 9NH, UK
| | - M Al-Memar
- Tommy's National Early Miscarriage Research Centre, Queen Charlottes & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - H Mitchell
- Hillingdon Hospital, Pield Heath Road, Uxbridge UB8 3NN, UK
| | - C Stalder
- Tommy's National Early Miscarriage Research Centre, Queen Charlottes & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK
| | - C Bottomley
- Chelsea & Westminster Hospital, 329 Fulham Road, London SW10 9NH, UK
| | - A Kothari
- Hillingdon Hospital, Pield Heath Road, Uxbridge UB8 3NN, UK
| | - D Timmerman
- Department of Development and Regeneration, KU Leuven, Herestraat 49 Box 7003, Leuven B-3000, Belgium Department of Obstetrics and Gynaecology, University Hospitals Leuven, Campus Gasthuisberg, KU Leuven, Belgium
| | - T Bourne
- Tommy's National Early Miscarriage Research Centre, Queen Charlottes & Chelsea Hospital, Imperial College, Du Cane Road, London W12 0HS, UK Department of Development and Regeneration, KU Leuven, Herestraat 49 Box 7003, Leuven B-3000, Belgium Department of Obstetrics and Gynaecology, University Hospitals Leuven, Campus Gasthuisberg, KU Leuven, Belgium
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Esterle J, Schieda J. Hemorrhagic heterotopic pregnancy in a setting of prior tubal ligation and re-anastomosis. J Radiol Case Rep 2015; 9:38-46. [PMID: 26629296 DOI: 10.3941/jrcr.v9i7.2386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Heterotopic pregnancy is the occurrence of simultaneous intrauterine and extrauterine pregnancies. Heterotopic pregnancy most commonly occurs during the first trimester of pregnancy in women who have significant risk factors including assisted reproductive therapy, prior ectopic pregnancy, and prior pelvic surgery or pelvic inflammatory disease. Although rare, heterotopic pregnancy must be recognized using ultrasound so as to provide appropriate treatment to the extrauterine pregnancy with the goal of preserving the intrauterine pregnancy. The case presented describes a patient with a pathologically proven (figure 8A and 8B), surgically treated 1st trimester heterotopic pregnancy.
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MESH Headings
- Adult
- Diagnosis, Differential
- Female
- Hemorrhage/diagnostic imaging
- Hemorrhage/pathology
- Hemorrhage/surgery
- Humans
- Pregnancy
- Pregnancy Trimester, First
- Pregnancy, Heterotopic/diagnostic imaging
- Pregnancy, Heterotopic/pathology
- Pregnancy, Heterotopic/surgery
- Pregnancy, Tubal/diagnostic imaging
- Pregnancy, Tubal/pathology
- Pregnancy, Tubal/surgery
- Risk Factors
- Sterilization Reversal
- Sterilization, Tubal
- Ultrasonography, Prenatal
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Affiliation(s)
- Jason Esterle
- Department of Radiology, MetroHealth System, Cleveland, Ohio, USA
| | - Jill Schieda
- Department of Radiology, MetroHealth System, Cleveland, Ohio, USA
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Si MJ, Gui S, Fan Q, Han HX, Zhao QQ, Li ZX, Zhao JM. Role of MRI in the early diagnosis of tubal ectopic pregnancy. Eur Radiol 2015; 26:1971-80. [DOI: 10.1007/s00330-015-3987-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 07/28/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
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Imaging of Acute and Emergent Genitourinary Conditions: What the Radiologist Needs to Know. AJR Am J Roentgenol 2015; 204:W631-9. [DOI: 10.2214/ajr.14.14117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass. Radiographics 2015; 35:946-59. [PMID: 25860721 DOI: 10.1148/rg.2015140202] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.
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Affiliation(s)
- Anjeza Chukus
- From the Department of Radiology, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140 (A.C., N.I.R.); Department of Radiology, George Washington University School of Medicine, Washington, DC (N.T.); and Department of Radiology, Miami Children's Hospital, Miami, Fla (R.R.)
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Cabar FR, Pereira PP, Schultz R, Francisco RP, Zugaib M. Association between ultrasound findings and serum levels of vascular endothelial growth factor in ampullary pregnancy. Fertil Steril 2015; 103:734-7. [PMID: 25577466 DOI: 10.1016/j.fertnstert.2014.12.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the association between ultrasound images and serum concentrations of vascular endothelial growth factor (VEGF) in ampullary pregnancies. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Fifty patients with ampullary pregnancy. INTERVENTION(S) Criteria for inclusion in the study were: singleton pregnancy from spontaneous conception; diagnosis of tubal pregnancy in the ampullary region; radical surgical treatment (salpingectomy); and measurement of serum VEGF, human chorionic gonadotropin, and progesterone on the day of surgery. An additional criterion was description of an ectopic mass by transvaginal ultrasound, as follows: [1] ectopic gestational sac containing an embryo with cardiac activity; and [2] tubal ring: a paraovarian formation similar to a gestational sac, not containing a viable embryo (an anechoic structure surrounded by a peripheral hyperechogenic halo); an empty ectopic gestational sac; a sac containing an embryo without cardiac activity; or a vitelline vesicle. MAIN OUTCOME MEASURE(S) Association between ultrasound images and serum concentrations of VEGF. RESULT(S) An association was found between ultrasonographic images and VEGF serum concentrations. Ectopic embryos with cardiac activity were associated with higher levels of serum VEGF. CONCLUSION(S) In ampullary pregnancy, higher serum levels of VEGF are associated with the finding of an embryo with cardiac activity on transvaginal ultrasound. Greater production of VEGF likely creates development conditions more conducive to ectopic embryos.
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Affiliation(s)
- Fábio Roberto Cabar
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil.
| | - Pedro Paulo Pereira
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil
| | - Regina Schultz
- Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Marcelo Zugaib
- Department of Obstetrics and Gynecology, University of São Paulo, São Paulo, Brazil
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Mazzariol FS, Roberts J, Oh SK, Ricci Z, Koenigsberg M, Stein MW. Pearls and pitfalls in first-trimester obstetric sonography. Clin Imaging 2014; 39:176-85. [PMID: 25457572 DOI: 10.1016/j.clinimag.2014.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 10/13/2014] [Accepted: 10/16/2014] [Indexed: 10/24/2022]
Abstract
Ultrasound is the primary imaging modality used in the evaluation of first-trimester vaginal bleeding and pelvic pain. This article will summarize the ultrasound findings in normal first-trimester pregnancy, failed pregnancy, ectopic pregnancy, subchorionic hemorrhage, retained products of conception, and gestational trophoblastic disease. Mastery of the spectrum of sonographic findings in the normal and abnormal first-trimester pregnancy allows the radiologist to make accurate diagnoses and helps to appropriately guide patient management.
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Affiliation(s)
- Fernanda S Mazzariol
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine.
| | - Jeffrey Roberts
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine
| | - Sarah K Oh
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine
| | - Zina Ricci
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine
| | - Mordecai Koenigsberg
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine
| | - Marjorie W Stein
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine
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Shetty VH, Gowda S, Muralidhar L. Role of ultrasonography in diagnosis of ectopic pregnancy with clinical analysis and management in tertiary care hospital. J Obstet Gynaecol India 2014; 64:354-7. [PMID: 25368460 DOI: 10.1007/s13224-014-0529-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 02/25/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE OF THE STUDY This study is undertaken to emphasize the role of ultrasonography in the diagnosis of ectopic pregnancy and clinical analysis of the same in a tertiary care referral hospital. METHODOLOGY One hundred patients with provisional diagnosis of ectopic pregnancy were studied. Physical examination, urine pregnancy test, transabdominal scan using 5 MHz transducer or transvaginal ultrasonography of 7 MHz was done. The diagnosis of ectopic pregnancy was confirmed by direct observation by laparotomy or laparoscopy (which was taken as gold standard). RESULTS The study showed ectopic pregnancy was most common in gravida 2 and in age group 26-30 years with most of them having married life <10 years. One or more risk factors were found in 66 % of cases. 54 % of cases presented with acute symptoms, 14 % of cases in shock. Among clinical presentation pain abdomen, history of amenorrhea, bleeding per vaginum, abdominal tenderness, and cervical motion tenderness was most common. In ultrasonography, complex mass in adnexa was present in 60 % of cases and hemoperitoneum in 50 %. 96 % of cases were tubal pregnancy with most of them tubal rupture. In 98 % of cases, radical surgery was done. Salpingectomy was the most common surgery done (90 %). There was no negative laparotomy in this study. There was no maternal mortality in this series. CONCLUSIONS In all the 100 cases of ectopic pregnancy studied, the ultrasonography provided definitive diagnosis resulting in 100 % sensitivity and 100 % specificity, predictive value of positive test being 100 %. Ultrasonography done in earlier weeks of gestation had sensitivity of 96 % and false negative 4 %.
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Affiliation(s)
- Vishma H Shetty
- Department of OBG, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP area, Whitefield, Bangalore, 560066 India
| | - Some Gowda
- Department of OBG, Bangalore Medical College and Research Institute, Sri Krishna Rajendra Road, City Market, Bangalore, 560002 India
| | - Lakshmidevi Muralidhar
- Department of OBG, Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP area, Whitefield, Bangalore, 560066 India
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Arleo EK, DeFilippis EM. Cornual, interstitial, and angular pregnancies: clarifying the terms and a review of the literature. Clin Imaging 2014; 38:763-70. [DOI: 10.1016/j.clinimag.2014.04.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/01/2014] [Accepted: 04/05/2014] [Indexed: 10/25/2022]
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Petrides A, Dinglas C, Chavez M, Taylor S, Mahboob S. Revisiting ectopic pregnancy: a pictorial essay. J Clin Imaging Sci 2014; 4:37. [PMID: 25161806 PMCID: PMC4142466 DOI: 10.4103/2156-7514.137817] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 05/28/2014] [Indexed: 11/04/2022] Open
Abstract
Ectopic pregnancies occur in approximately 1.4% of all pregnancies and account for 15% of pregnancy-related deaths. Considering the high degree of mortality, recognizing an ectopic pregnancy is important. Signs and symptoms of an ectopic pregnancy are nonspecific and include pain, vaginal bleeding, and an adnexal mass. Therefore, imaging can play a critical role in diagnosis. There are different types of ectopic pregnancies, which are tubal, cornual, cesarean scar, cervical, heterotopic, abdominal, and ovarian. Initial imaging evaluation of pregnant patients with pelvic symptoms is by ultrasonography, transabdominal, transvaginal or both. We review the sonographic appearance of different types of ectopic pregnancies that will aid in accurate and prompt diagnosis.
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Affiliation(s)
- Artemis Petrides
- Department of Radiology, Winthrop University Hospital, New York, USA
| | - Cheryl Dinglas
- Department Obstetrics and Gynecology, Winthrop University Hospital, New York, USA
| | - Martin Chavez
- Department Obstetrics and Gynecology, Winthrop University Hospital, New York, USA
| | - Sharon Taylor
- Department of Radiology, Winthrop University Hospital, New York, USA
| | - Sabrina Mahboob
- Department of Radiology, Winthrop University Hospital, New York, USA ; Department of Radiology, SUNY Stony Brook School of Medicine, New York, USA
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Lewiss RE, Shaukat NM, Saul T. The endomyometrial thickness measurement for abnormal implantation evaluation by pelvic sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1143-1146. [PMID: 24958399 DOI: 10.7863/ultra.33.7.1143] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Emergency physicians, obstetrician-gynecologists, and other medical specialists use pelvic sonography when caring for patients presenting with early pregnancy-related symptoms. A thin endomyometrial mantle and eccentric placement of a gestational sac should raise the suspicion for an abnormally implanted pregnancy. In such cases, an interstitial ectopic pregnancy or a cornual pregnancy, two clinically distinct entities, must be considered. This article reviews the literature and guidelines on the sonographic measurement of the endomyometrial mantle as a criterion for determining a pregnancy at risk for an abnormal implantation location. We sought to clarify the history and evolution of this measurement to determine what should be considered an abnormal measurement and to understand its diagnostic utility and management implications for the clinician using sonography.
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Affiliation(s)
- Resa E Lewiss
- Department of Emergency Medicine, St Luke's-Roosevelt Hospital Center, New York, New York USA (R.E.L., T.S.); and Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York USA (N.M.S.)
| | - Nadia M Shaukat
- Department of Emergency Medicine, St Luke's-Roosevelt Hospital Center, New York, New York USA (R.E.L., T.S.); and Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York USA (N.M.S.)
| | - Turandot Saul
- Department of Emergency Medicine, St Luke's-Roosevelt Hospital Center, New York, New York USA (R.E.L., T.S.); and Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York USA (N.M.S.)
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Gnisci A, Stefani L, Bottin P, Ohannessian A, Gamerre M, Agostini A. Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational comparative study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:698-701. [PMID: 24265158 DOI: 10.1002/uog.13255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 10/28/2013] [Accepted: 11/07/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To assess the predictive value of hemoperitoneum for the outcome of methotrexate (MTX) treatment of ectopic pregnancy (EP). METHODS This observational prospective single-center study included women presenting with EP treated with MTX from November 2007 to November 2009. The percentage of women with hemoperitoneum at the beginning of MTX treatment was compared between two groups: those whose treatment was successful and those whose treatment failed. The rate of hemoperitoneum in each group and its value in predicting the outcome of MTX treatment of EP were assessed. RESULTS MTX treatment was successful in 69 of 93 (74%) cases. The percentage of women with hemoperitoneum at the beginning of treatment was significantly higher in women in whom MTX treatment failed as compared to those in whom it was successful (15/24 (62.5%) vs 17/69 (24.6%); P = 0.001). The likelihood of requiring surgery following treatment with MTX was higher in women with hemoperitoneum (odds ratio, 5.1; 95% CI, 1.74-15.14). Study of the diagnostic performance of hemoperitoneum in predicting the need for surgical treatment after MTX treatment revealed a sensitivity of 0.63, a specificity of 0.76, a positive predictive value of 0.47 and a negative predictive value of 0.85. CONCLUSIONS The presence of hemoperitoneum appears to be a risk factor for MTX treatment failure. It is important to inform women as fully as possible about the risk of such failure. Nonetheless, the predictive value of this sign is insufficient for either routinely excluding women with hemoperitoneum from MTX treatment or omitting post-treatment monitoring.
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Affiliation(s)
- A Gnisci
- Service de Gynécologie Obstétrique, Hôpital La Conception, Marseille, France
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Chrestiana D, Cheng AB, Panebianco NL, Dean AJ. Pitfalls in cervical ectopic pregnancy diagnosis by emergency physicians using bedside ultrasonography. Am J Emerg Med 2014; 32:397.e1-3. [DOI: 10.1016/j.ajem.2013.10.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/30/2013] [Indexed: 11/27/2022] Open
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