Ultrasound assessment of haemoperitoneum in ectopic pregnancy: derivation of a prediction model

Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery - The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood

OBJECTIVES

Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency.

METHODS

Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves.

RESULTS

Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794-0.879) and high urgency (AUC 0.902, 95 % CI 0.860-0.945).

CONCLUSION

Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.

Prediction of Rupture by Complete Blood Count in Tubal Ectopic Pregnancies Treated with a Single-Dose Methotrexate Protocol

OBJECTIVE

 The availability of reliable and inexpensive markers that can be used to determine the risk of rupture during methotrexate (MTX) treatment in ectopic pregnancies (EPs) is considerable. The aim of the present study is to investigate the role of systemic inflammatory markers such as leukocytes (or white blood cells, WBCs), the neutrophil-to-lymphocyte ratio (NLR), and platelet distribution width (PDW), which are among the parameters of the complete blood count (CBC), in the prediction of rupture of EPs under MTX treatment.

MATERIALS AND METHODS

 A total of 161 patients with tubal EP who underwent a single-dose methotrexate (MTX) protocol were retrospectively analyzed, and the control group (n = 83) included patients cured by MTX, while the ruptured group (n = 78) included patients who were operated on for tubal rupture during the MTX treatment. The features of EP, beta-human chorionic gonadotropin (β-hCG) levels, sonographic findings, and CBC-derived markers such as WBC, NLR, and PDW, were investigated by comparing both groups.

RESULTS

 The NLR was found to be higher in the ruptured group, of 2.92 ± 0.86%, and significantly lower in the control group, of 2.09 ± 0.6%. Similarly, the PDW was higher (51 ± 9%) in the ruptured group, and it was significantly lower a (47 ± 13%) in the control group (p < 0.05). Other CBC parameters were similar in both groups (p > 0.05).

CONCLUSION

 Systemic inflammation markers derived from CBC can be easily applied to predict the risk of tubal rupture in Eps, since the CBC is an inexpensive and easy-to-apply test, which is first requested from each patient during hospitalization.

Impact of point-of-care ultrasound on treatment time for ectopic pregnancy

BACKGROUND

Point-of-care ultrasound (POCUS) is useful in the evaluation of early pregnancy by confirming intrauterine pregnancy and recognizing hemorrhage from ectopic pregnancy. We sought to determine whether transabdominal POCUS by itself or in conjunction with consultative radiology ultrasound (RADUS), reduces Emergency Department (ED) treatment time for patients with ectopic pregnancy requiring operative care, when compared to RADUS alone. A secondary objective was to determine whether the incorporation of POCUS reduces time to operative care for patients with ruptured ectopic pregnancy specifically, when compared to RADUS alone.

METHODS

We performed a retrospective review of patients admitted for operative management of ectopic pregnancy. We excluded patients with known ectopic pregnancy and/or imaging prior to arriving to the treatment area, found not to have an ectopic pregnancy, or did not undergo operative care. Descriptive statistics, classical and nonparametric statistical analysis, and linear regression were performed.

RESULTS

There were 220 patients admitted with ectopic pregnancy, 111 met exclusion criteria, yielding 109 for analysis. Of 109, 36 received POCUS (23/36 also had RADUS), while 73 received RADUS only. Among the POCUS group 31/36 (86%) were classified as ruptured versus 47/73 (64%) in the RADUS group. The average ED treatment time in the POCUS group for all admitted ectopic pregnancies was 157.9 min (standard deviation [SD] 101.3) versus 206.3 min (SD 76.6) in the RADUS group (p = 0.0141). The median time to operating room (OR) for ruptured ectopic pregnancies was 203.0 min (interquartile range [IQR] 159.0) in the POCUS group versus 293.0 min (IQR 139.0) in the RADUS group (p = 0.0002). Regression analysis of the primary outcome was limited by multiple interactions and sample size. When controlling for race, positive shock index and ED visit time, POCUS was found to be associated with a significantly shorter time to OR among ruptured ectopic pregnancies compared to RADUS (p = 0.0052).

CONCLUSION

Compared to RADUS alone, incorporation of POCUS was associated with significantly faster ED treatment time for all ectopic pregnancies and significantly faster time to OR for ruptured ectopic pregnancies, even when combined with RADUS. When controlling for clinical differences, time to OR was still faster for patients who underwent POCUS. The integration of POCUS should be considered to expedite care for patients with ectopic pregnancy requiring operative care.

Terminology for describing normally sited and ectopic pregnancies on ultrasound: ESHRE recommendations for good practice

STUDY QUESTION

What recommendations can be provided to improve terminology for normal and ectopic pregnancy description on ultrasound?

SUMMARY ANSWER

The present ESHRE document provides 17 consensus recommendations on how to describe normally sited and different types of ectopic pregnancies on ultrasound.

WHAT IS KNOWN ALREADY

Current diagnostic criteria stipulate that each type of ectopic pregnancy can be defined by clear anatomical landmarks which facilitates reaching a correct diagnosis. However, a clear definition of normally sited pregnancies and a comprehensive classification of ectopic pregnancies are still lacking.

STUDY DESIGN SIZE DURATION

A working group of members of the ESHRE Special Interest Group in Implantation and Early Pregnancy (SIG-IEP) and selected experts in ultrasound was formed in order to write recommendations on the classification of ectopic pregnancies.

PARTICIPANTS/MATERIALS SETTING METHODS

The working group included nine members of different nationalities with internationally recognised experience in ultrasound and diagnosis of ectopic pregnancies on ultrasound. This document is developed according to the manual for development of ESHRE recommendations for good practice. The recommendations were discussed until consensus by the working group, supported by a survey among the members of the ESHRE SIG-IEP.

MAIN RESULTS AND THE ROLE OF CHANCE

A clear definition of normally sited pregnancy on ultrasound scan is important to avoid misdiagnosis of uterine ectopic pregnancies. A comprehensive classification of ectopic pregnancy must include definitions and descriptions of each type of ectopic pregnancy. Only a classification which provides descriptions and diagnostic criteria for all possible locations of ectopic pregnancy would be fit for use in routine clinical practice. The working group formulated 17 recommendations on the diagnosis of the different types of ectopic pregnancies on ultrasound. In addition, for each of the types of ectopic pregnancy, a schematic representation and examples on 2D and 3D ultrasound are provided.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical and technical expertise.

WIDER IMPLICATIONS OF THE FINDINGS

This document is expected to have a significant impact on clinical practice in ultrasound for early pregnancy. The development of this terminology will help to reduce the risk of misdiagnosis and inappropriate treatment.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESHRE. T.T. declares speakers' fees from GE Healthcare. The other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

DISCLAIMER

This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation. ESHRE's GPRs should be used for informational and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. Furthermore, ESHRE's GPRs do not constitute or imply the endorsement, recommendation or favouring of any of the included technologies by ESHRE.

Ectopic pregnancies: Catch them early, treat them wisely!

Introduction:

Ectopic pregnancy (EP) is a common condition encountered in Obstetrics and Gynecology. Different management protocols are currently available for haemodymanically stable patients but definitive recommendations is yet to be established, especially in developing countries with limited resources.

Aim:

To determine the outcome of EP in patients who are haemodynamically stable and to evaluate the factors that would predict success of specific management protocols in them.

Methodology:

Haemodynamically stable patients with HCG levels <1500 mIU/ml were recruited for expectant management, 1500–5000 mIU/ml were given MTX and those with >5000 mIU/ml were managed surgically.

Results:

The overall success rate for expectant management was 92.7% and that with MTX was 80%. Baseline HCG values was found to be the only significant factor for predictor of success of treatment in the expectant group (P 0.05). The size of mass seen on USG did not have a significant correlation with beta HCG values (P 0.257).

Conclusion:

Of all the predictors for success of treatment that have been studied, the initial HCG value alone remains of paramount importance. Women with initial values of HCG <1500 mIU/ml can be offered expectant management, with a much better assurance of success for those with values <1000 mIU/ml. Those with values <5000 mIU/ml can be given MTX, with single dose being sufficient most often for <3000 mIU/ml. The presence of fluid restricted to the pelvis on USG can be managed non-surgically. One should not opt for surgical management only on the basis of size of the adnexal mass on USG.

Guidelines for minimal report in gynaecologic sonography: Are they useful for emergency department resident physicians?

OBJECTIVES

This study aimed to evaluate the impact of Collège National des Gynécologues et Obstétriciens Français (CNGOF) guidelines on the minimal sonographic reports generated by emergency department resident physicians.

MATERIAL AND METHODS

This prospective observational study was conducted in the gynaecologic emergency unit of a teaching hospital from November 2016 to May 2017. We analysed sonographic reports generated by residents during gynaecological emergencies before and after training on the minimal report standards. An analysis of the evaluated items was carried out. We also compared residents according to their specialities and seniority.

RESULTS

A total of 240 reports were analysed, 120 before and 120 after the training. Half of the reports concerned women with an early pregnancy while the others concerned women with negative hCG. All residents significantly improved their practice after the training, as shown by the increase in ratings of the evaluated items (38 % before training vs 44.8 % after, p < 0.01). General practitioners had greater improvement (48.1 % of evaluated items), whereas older residents reported fewer items before or after the training (43.5 %) than younger residents. Finally, all residents improved their practice with a conclusion that followed the guidelines in 92.5 % of cases (versus 68.3 % before the training; p < 0.01).

CONCLUSION

Training on the CNGOF minimal sonographic report guidelines significantly improved the emergency sonographic reports generated by residents. Wider dissemination of this training, particularly to young residents, would probably improve the quality of sonographic reports performed at gynaecological emergencies.

Relationship Between Ultrasonographic and Biochemical Markers of Tubal Ectopic Pregnancy and Success of Subsequent Management

OBJECTIVES

To determine whether there is an association between morphologic types of tubal ectopic pregnancy (EP), 0-hour human chorionic gonadotropin (hCG) levels, and subsequent management success.

METHODS

We conducted a prospective study (November 2006-December 2015). Women had a diagnosis of EP by transvaginal ultrasonography if they had an inhomogeneous mass adjacent to the ovary and moving separately from it ("blob" sign), a mass with a hyperechoic ring around the gestational sac ("bagel" sign), or a gestational sac with an embryonic pole with or without a yolk sac with or without cardiac activity. The morphologic type, EP size, and 0-hour hCG level were analyzed. A multivariate analysis determined any correlation between these variables and nonsurgical management success.

RESULTS

A total of 7350 consecutive women underwent transvaginal ultrasonography, of whom 301 (4.2%) had a diagnosis of tubal EP; 181 (60.1%) had the blob sign; 90 (29.9%) had the bagel sign; and 23 (7.6%) were noted to have an embryo (14 viable and 9 nonviable). Eighty-three of 301(27.5%) women had expectant management; 67 of 301(22.2%) were given methotrexate; and 151 of 301 (50%) had surgery. Success rates for the groups were 77%, 75%, and 100%, respectively. No difference between the morphologic type and success rate of treatment was noted. Although there was a significant correlation between the EP mass size and 0-hour hCG level, the mass size itself was not correlated with the success rate of either medical or expectant management. Overall higher 0-hour hCG levels were associated with management failure. In the expectant group, median hCG level for failure was 589 IU/L versus 366 IU/L for success, whereas in the medical group, the median for failure was 1244 IU/L versus 7629 IU/L for success.

CONCLUSIONS

There is no significant correlation between the morphologic type and size of EP with a nonsurgical management outcome. A likely successful outcome is related to a lower level of serum hCG at presentation.

How to measure size of tubal ectopic pregnancy on ultrasound

OBJECTIVE

To identify the preoperative ultrasound parameters for assessing the size of tubal ectopic pregnancy that correlate best with findings at surgery.

METHODS

This was a prospective study of all women attending our center who had a conclusive transvaginal ultrasound diagnosis of tubal ectopic pregnancy over a 10-month period. In each case, the total size of the ectopic pregnancy was measured by placing the calipers on the outer edges of the visible trophoblastic tissue. In ectopic pregnancies presenting with a well-defined gestational sac, the size of the celomic (chorionic) cavity was also measured using the inner borders of the trophoblastic ring as reference points. In women with signs of intra-abdominal bleeding, the size of the hematosalpinx and/or hemoperitoneum was measured. Surgeons were blinded to the ultrasound measurements and were asked to estimate the size of the ectopic pregnancy and the amount of hemoperitoneum intraoperatively.

RESULTS

A total of 105 women were diagnosed with a tubal ectopic pregnancy on ultrasound examination, of whom 71 (67.6%) were managed surgically. A significant (P < 0.01) positive correlation was found between all ultrasound measurements and the size of the tubal ectopic pregnancy as reported during surgery. In the absence of hematosalpinx, the mean total outer diameter of the ectopic pregnancy had the highest positive correlation with the size of the tubal ectopic pregnancy at surgery (r = 0.65, P < 0.001). In cases complicated by hematosalpinx, the mean diameter of the tube was the only variable that correlated significantly with the estimated size of the ectopic pregnancy at surgery (P < 0.001). There was a significant positive association between the amount of hemoperitoneum on ultrasound and the estimated volume of intraperitoneal blood at surgery (P < 0.001).

CONCLUSIONS

The mean size of a hematosalpinx and the total outer mean diameter of an ectopic pregnancy on ultrasound correlate better with the surgical findings than does the size of the celomic cavity. Our findings show that the standard approach of measuring the size of an intrauterine pregnancy on ultrasound should be adapted to include these additional measurements in women diagnosed with a tubal ectopic pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Prediction of Tubal Ectopic Pregnancy Using Offline Analysis of 3-Dimensional Transvaginal Ultrasonographic Data Sets: An Interobserver and Diagnostic Accuracy Study

OBJECTIVES

To assess interobserver reproducibility in detecting tubal ectopic pregnancies by reading data sets from 3-dimensional (3D) transvaginal ultrasonography (TVUS) and comparing it with real-time 2-dimensional (2D) TVUS.

METHODS

Images were initially classified as showing pregnancies of unknown location or tubal ectopic pregnancies on real time 2D TVUS by an experienced sonologist, who acquired 5 3D volumes. Data sets were analyzed offline by 5 observers who had to classify each case as ectopic pregnancy or pregnancy of unknown location. The interobserver reproducibility was evaluated by the Fleiss κ statistic. The performance of each observer in predicting ectopic pregnancies was compared to that of the experienced sonologist. Women were followed until they were reclassified as follows: (1) failed pregnancy of unknown location; (2) intrauterine pregnancy; (3) ectopic pregnancy; or (4) persistent pregnancy of unknown location.

RESULTS

Sixty-one women were included. The agreement between reading offline 3D data sets and the first real-time 2D TVUS was very good (80%-82%; κ = 0.89). The overall interobserver agreement among observers reading offline 3D data sets was moderate (κ = 0.52). The diagnostic performance of experienced observers reading offline 3D data sets had accuracy of 78.3% to 85.0%, sensitivity of 66.7% to 81.3%, specificity of 79.5% to 88.4%, positive predictive value of 57.1% to 72.2%, and negative predictive value of 87.5% to 91.3%, compared to the experienced sonologist's real-time 2D TVUS: accuracy of 94.5%, sensitivity of 94.4%, specificity of 94.5%, positive predictive value of 85.0%, and negative predictive value of 98.1%.

CONCLUSIONS

The diagnostic accuracy of 3D TVUS by reading offline data sets for predicting ectopic pregnancies is dependent on experience. Reading only static 3D data sets without clinical information does not match the diagnostic performance of real time 2D TVUS combined with clinical information obtained during the scan.

Optimal Combination of Non-Invasive Tools for the Early Detection of Potentially Life-Threatening Emergencies in Gynecology

Objectives

Potentially life-threatening gynecological emergencies (G-PLEs) are acute pelvic conditions that may spontaneously evolve into a life-threatening situation, or those for which there is a risk of sequelae or death in the absence of prompt diagnosis and treatment. The objective of this study was to identify the best combination of non-invasive diagnostic tools to ensure an accurate diagnosis and timely response when faced with G-PLEs for patients arriving with acute pelvic pain at the Gynecological Emergency Department (ED).

Methods

The data on non-invasive diagnostic tools were sourced from the records of patients presenting at the ED of two hospitals in the Parisian suburbs (France) with acute pelvic pain between September 2006 and April 2008. The medical history of the patients was obtained through a standardized questionnaire completed for a prospective observational study, and missing information was completed with data sourced from the medical forms. Diagnostic tool categories were predefined as a collection of signs or symptoms. We analyzed the association of each sign/symptom with G-PLEs using Pearson’s Chi-Square or Fischer’s exact tests. Symptoms and signs associated with G-PLEs (p-value < 0.20) were subjected to logistic regression to evaluate the diagnostic value of each of the predefined diagnostic tools and in various combinations.

Results

The data of 365 patients with acute pelvic pain were analyzed, of whom 103 were confirmed to have a PLE. We analyzed five diagnostic tools by logistic regression: Triage Process, History-Taking, Physical Examination, Ultrasonography, and Biological Exams. The combination of History-Taking and Ultrasonography had a C-index of 0.83, the highest for a model combining two tools.

Conclusions

The use of a standardized self-assessment questionnaire for history-taking and focal ultrasound examination were found to be the most successful tool combination for the diagnosis of gynecological emergencies in a Gynecological ED. Additional tools, such as physical examination, do not add substantial diagnostic value.

Triage using a self-assessment questionnaire to detect potentially life-threatening emergencies in gynecology

Objective

Acute pelvic pain is a common reason for emergency room visits that can indicate a potentially life-threatening emergency (PLTE). Our objective here was to develop a triage process for PLTE based on a self-assessment questionnaire for gynecologic emergencies (SAQ-GE) in patients experiencing acute pelvic pain.

Methods

In this multicenter prospective observational study, all gynecological emergency room patients seen for acute pelvic pain between September 2006 and April 2008 completed the SAQ-GE after receiving appropriate analgesics. Diagnostic procedures were ordered without knowledge of questionnaire replies. Laparoscopy was the reference standard for diagnosing PLTE; other diagnoses were based on algorithms. In two-thirds of the population, SAQ-GE items significantly associated with PLTEs (P < 0.05) by univariate analysis were used to develop a decision tree by recursive partitioning; the remaining third served for validation.

Results

Of 344 derivation-set patients and 172 validation-set patients, 96 and 49 had PLTEs, respectively. Items significantly associated with PLTEs were vomiting, sudden onset of pain, and pain to palpation. Sensitivity of the decision tree based on these three features was 87.5% (95% confidence interval (95% CI), 81%-94%) in the derivation set and 83.7% in the validation set. Derivation of the decision tree provided probabilities of PLTE of 13% (95% CI, 6%-19%) in the low-risk group, 27% (95% CI, 20%-33%) in the intermediate-risk group and 62% (95% CI, 48%-76%) in the high-risk group, ruling out PLTE with a specificity of 92.3%; (95% CI, 89%-96%). In the validation dataset, PLTE probabilities were 16.3% in the low-risk group, 30.6% in the intermediate-risk group, and 44% in the high-risk group, ruling out the diagnosis of PLTE with a specificity of 88.6%.

Conclusion

A simple triage model based on a standardized questionnaire may assist in the early identification of patients with PLTEs among patients seen in the gynecology emergency room for acute pelvic pain.

Routine ultrasound examination by OB/GYN residents increase the accuracy of diagnosis for emergency surgery in gynecology

Introduction

Diagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain.

Methods

A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both.

Results

Emergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%.

Conclusions

First-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.

Phase II single arm open label multicentre clinical trial to evaluate the efficacy and side effects of a combination of gefitinib and methotrexate to treat tubal ectopic pregnancies (GEM II): study protocol

INTRODUCTION

Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. tEPs with pretreatment serum human chorionic gonadotrophin (hCG) levels <1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate (MTX). TEPs with hCG >1000 IU/L take a significant time to resolve with MTX and require multiple outpatient monitoring visits. Gefitinib is an orally active epidermal growth factor receptor (EGFR) antagonist. In preclinical studies, we found that EP implantation sites express high levels of EGFR and that gefitinib augments MTX-induced regression of pregnancy-like tissue. We performed a phase I toxicity study administering oral gefitinib and intramuscular MTX to 12 women with tEPs. The combination therapy did not cause significant toxicities and was well tolerated. We noted that combination therapy resolved the tEPs faster than MTX alone. We now describe the protocol of a larger single arm trial to estimate the efficacy and side effects of combination gefitinib and MTX to treat stable tEPs with hCG 1000-10 000 IU/L METHODS AND ANALYSIS: We propose to undertake a single-arm multicentre open label trial (in Edinburgh and Melbourne) and recruit 28 women with tEPs (pretreatment serum hCG 1000-10 000 IU/L). We intend to give a single dose of intramuscular MTX (50 mg/m(2)) and oral gefitinib (250 mg) daily for 7 days. Our primary outcome is the resolution of EP to non-pregnant hCG levels <15 IU/L without requirement of surgery. Our secondary outcomes are comparison of time to resolution against historical controls given MTX only, and safety and tolerability as determined by clinical/biochemical assessment.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Scotland A Research Ethics Committee (MREC 11/AL/0350), Southern Health Human Research Ethics Committee B (HREC 11180B) and the Mercy Health Human Research Ethics Committee (R12/25). Data will be presented at international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12611001056987.

Does tubal ectopic pregnancy with hemoperitoneum always require surgery?

OBJECTIVE

Hemoperitoneum is accepted as an indication for surgery in women with tubal ectopic pregnancy. The aim of this pilot study was to evaluate the feasibility of managing such women non-surgically.

METHODS

This was a prospective observational study. Women with tubal ectopic pregnancy and hemoperitoneum detected on transvaginal sonography (TVS) were managed as inpatients either expectantly or with methotrexate (MTX). Inclusion criteria for conservative management were: compliance, clinical stability, absence of acute abdomen, stable hemoglobin level on two measurements (0 and 12-24 h apart), serum human chorionic gonadotropin (hCG) < 5000 IU/L, absence of fetal cardiac activity on TVS and absence of significant hemoperitoneum, defined as blood above the level of the uterine fundus and/or in Morison's pouch (hepatorenal space). Subsequent management was based upon the hCG ratio at 48 h. All the women were managed as inpatients until the abdominal pain settled and the serum hCG levels were falling.

RESULTS

Forty-one women with tubal ectopic pregnancy presented between November 2006 and March 2008. Eight women (20%) fulfilled the entry criteria. The median gestational age at diagnosis was 49 (interquartile range, 38-52.5) days. All women presented with lower abdominal pain/right iliac fossa or left iliac fossa pain. Hemoglobin levels ranged from 11.2 to 14.2 g/dL at presentation and from 12.0 to 14.8 g/dL after 12-24 h. 6/8 (75%) women were managed expectantly and 2/8 (25%) received MTX. All women had resolution of their ectopic pregnancy within 3 weeks with no complications.

CONCLUSIONS

This pilot study suggests that the finding of hemoperitoneum on ultrasound examination may not be an absolute contraindication to conservative management of tubal ectopic pregnancy.