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Kugelman N, Cohen B, Yossef F, Margieh N, Regev N, Shani U, Bart Y. Expectant management of tubal pregnancies with human chorionic gonadotropin up to 2000 mIU/mL. Int J Gynaecol Obstet 2024; 164:1094-1100. [PMID: 37776069 DOI: 10.1002/ijgo.15162] [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: 06/23/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To describe outcomes of expectant management (EM) versus methotrexate (MTX) treatment in tubal pregnancies with pretreatment human chorionic gonadotropin (hCG) less than 2000 mIU/mL. METHODS This retrospective cohort from two tertiary hospitals included women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL. Exclusion criteria were unrecorded pregnancy site, unconfirmed diagnosis, and surgical treatment upon diagnosis. The primary outcome was eventual rate of surgical treatment. RESULTS Between December 2009 and June 2021, 545 of 2114 (25.8%) women diagnosed with a tubal pregnancy met our inclusion criteria. We compared women who underwent EM (N = 201) with women who received MTX (N = 344). All women in the EM group had a declining trend of hCG. The MTX group had higher pretreatment hCG and higher rates of yolk sac or embryo presence on ultrasound. Eventual surgical treatment rate was higher in the MTX group compared with the EM group (39 [11.3%] vs. 9 [4.5%], P = 0.006), with no difference in the treatment failure rate or tubal rupture rate. In a subgroup analysis of women with pretreatment hCG between 1000 and 2000 mIU/mL, eventual surgical treatment, treatment failure, and tubal rupture rates did not differ between groups. Logistic regression analysis revealed that eventual surgical treatment was independently associated with hCG levels less than 1000 mIU/mL (adjusted odds ratio [aOR] 0.28, 95% confidence interval [CI] 0.14-0.56) and endometriosis (aOR 9.20, 95% CI 3.55-23.81). CONCLUSION Expectant management of tubal pregnancies with pretreatment hCG levels less than 2000 mIU/mL and even between 1000 and 2000 mIU/mL and with a declining trend of hCG demonstrated lower or comparable rates of eventual surgical treatment, when compared with MTX treatment.
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Affiliation(s)
- Nir Kugelman
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Bracha Cohen
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Fayrooz Yossef
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Haifa, Israel
| | - Nadine Margieh
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Noam Regev
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Uria Shani
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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Davis AA, Lata K, Panwar A, Kriplani A. Unexpected rupture of an expectantly managed tubal ectopic pregnancy: a reminder for enhanced diligence. BMJ Case Rep 2019; 12:e230876. [PMID: 31888919 PMCID: PMC6936481 DOI: 10.1136/bcr-2019-230876] [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] [Accepted: 12/16/2019] [Indexed: 11/03/2022] Open
Abstract
Expectant management of tubal ectopic pregnancies is a feasible and possibly preferable method of management in asymptomatic women with low serum β-human chorionic gonadotropin (hCG). This involves serial monitoring of β-hCG until negative, after which it is deemed as spontaneously resolved ectopic pregnancy. We describe a case of tubal ectopic pregnancy which was expectantly managed with an initial β-hCG of 585 mIU/mL until undetectable. This patient presented with ruptured ectopic pregnancy 8 weeks after the original diagnosis, at the level of 5 mIU/mL. This highlights the importance of close monitoring in the expectant management of tubal ectopic pregnancies, with the incorporation of imaging, even when serial β-hCG shows a persistently reducing trend.
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Affiliation(s)
- Amenda Ann Davis
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
| | - Kusum Lata
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
| | - Akshita Panwar
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
| | - Alka Kriplani
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
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Nadim B, Lu C, Infante F, Reid S, Condous G. Relationship Between Ultrasonographic and Biochemical Markers of Tubal Ectopic Pregnancy and Success of Subsequent Management. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2899-2907. [PMID: 29675930 DOI: 10.1002/jum.14652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Batool Nadim
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Chuan Lu
- Department of Computer Sciences, Aberystwyth University, Aberystwyth, Wales
| | - Fernando Infante
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Shannon Reid
- Department of Obstetrics and Gynecology Wollongong Hospital, Wollongong, New South Wales, Australia
| | - George Condous
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
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Aydoğmuş S, Aydoğmuş H, Gençdal S, Kelekçi S. Density of tubal ring vascularization: A new marker for prediction of success of medical treatment in tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2017; 217:113-118. [PMID: 28888180 DOI: 10.1016/j.ejogrb.2017.08.022] [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: 04/01/2017] [Revised: 07/19/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The diagnosis of ectopic pregnancy has been facilitated especially by the use of Doppler ultrasonography. In previous studies the presence of peri-trophoblastic blood flow by Doppler ultrasound and the detection of a low-resistance, high-velocity flow pattern were defined as specific signs for trophoblastic tissue. The aim of this study was to evaluate the efficacy of Doppler ultrasonography in the prediction of treatment success in tubal pregnancies being treated with single dose conservative methotrexate. STUDY DESIGN A total of 104 patients with non-ruptured ectopic pregnancy who were hemodynamically stable and eligible for methotrexate treatment were included in the study. The spectral wave form of the mass was classified according to the vascularization density by Power Doppler. It was defined as Grade 1, 2 and 3, respectively. All patients received a single 50mg/m2 dose of systemic methotrexate. Serum β-hCG levels were measured on the 4th and 7th days of treatment. The treatment was considered unsuccessful in patients without a decrease of 15% or more in the serum β-hCG levels between days 0 and 7. RESULTS Twenty-four patients with grade I vascularity, 11 patients with grade II vascularity and 13 patients with grade III vascularity were referred as Group I, II and III, respectively, according to the degree of adnexal vascularity assessed by Doppler ultrasonography. Overall success rate of MTX treatment was found to be 72.9%. The response rates to systemic MTX treatment in cases with Grade I, II and III ectopic pregnancy mass vascularization were found to be 58.3%, 81.8% and 92.3%, respectively. Comparison of the groups' treatment responses revealed a linear-by-linear correlation with the Chi-square test. Increased vascularization grade of ectopic pregnancy was associated with a higher likelihood of responding to MTX treatment. CONCLUSIONS Detection of the vascularization grade with Doppler ultrasound could be considered a remarkable parameter in predicting treatment success considering its ease of utilization and low cost.
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Affiliation(s)
- Serpil Aydoğmuş
- İzmir Katip Çelebi University, School of Medicine Department of Obstetrics and Gynecology, İzmir, Turkey; İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey.
| | - Hüseyin Aydoğmuş
- İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
| | - Servet Gençdal
- İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
| | - Sefa Kelekçi
- İzmir Katip Çelebi University, School of Medicine Department of Obstetrics and Gynecology, İzmir, Turkey; İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
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Reid S, Condous G. Is there a need to definitively diagnose the location of a pregnancy of unknown location? The case for "no". Fertil Steril 2013; 98:1085-90. [PMID: 23084010 DOI: 10.1016/j.fertnstert.2012.09.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 11/25/2022]
Abstract
The ability to predict the outcome of a pregnancy of unknown location (PUL) has been extensively studied over the past decade. Between 8%-14% of PULs will develop into ectopic pregnancies (EP), and therefore the need to confirm pregnancy location is not without good reason. Strategies to predict EP in the PUL population have included the use of various maternal serum biomarkers and repeat transvaginal ultrasound (TVS) examinations in order to avoid delaying this diagnosis. These follow-up tests are associated with substantial financial cost to the healthcare system, as well as impacting on maternal anxiety. However, the majority of women with a PUL at follow-up will either have an intra-uterine pregnancy or a spontaneously resolving PUL, and therefore represent low-risk PULs. Most of these low-risk PULs do not need intervention and expectant management has been shown to be safe and not associated with adverse outcomes. Therefore we need consider whether the current strategies to determine pregnancy location are indeed essential for women with a PUL, especially when balancing the additional health care burden with the potential increase in maternal morbidity/mortality associated with delay in diagnosis. This beckons the question, "Do we really need to definitively diagnose pregnancy location in women with a PUL?
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Affiliation(s)
- Shannon Reid
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia.
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Chen ZY, Liu JH, Liang K, Liang WX, Ma SH, Zeng GJ, Xiao SY, He JG. The diagnostic value of a multivariate logistic regression analysis model with transvaginal power Doppler ultrasonography for the prediction of ectopic pregnancy. J Int Med Res 2012; 40:184-93. [PMID: 22429358 DOI: 10.1177/147323001204000119] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A multivariate logistic regression analysis model for predicting ectopic pregnancy in women with pregnancy of unknown location was designed and evaluated clinically. METHODS Endometrial thickness, symmetry, resonance, pattern of echogenicity, helicine artery blood flow and blood flow resistance index (RI) in 129 patients with suspected early ectopic pregnancy were assessed by transvaginal power Doppler ultrasonography. Variables significant in univariate logistic regression analysis were included in a multivariate predictive logistic regression analysis model. RESULTS The final predictive model included three factors: endometrial thickness≤9 mm; a multilayered endometrial echogenicity pattern with prominent outer and midline hyperechogenic lines and an inner hypoechogenic region; and visible endometrial arterial blood flow. The area under the receiver operating characteristic curve of the model was 0.980. When RI was >0.65 and the predictive probability>0.50, diagnostic accuracy was high. The model correctly diagnosed 52/55 (94.5%) clinically confirmed ectopic pregnancy cases. CONCLUSION This multivariate predictive logistic regression analysis model has clinical value for the differential diagnosis of early ectopic pregnancy when the pregnancy location is unknown.
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Affiliation(s)
- Z-Y Chen
- Department of Medical Ultrasound, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Goksedef BPC, Kef S, Akca A, Bayik RNE, Cetin A. Risk factors for rupture in tubal ectopic pregnancy: definition of the clinical findings. Eur J Obstet Gynecol Reprod Biol 2011; 154:96-9. [PMID: 20888681 DOI: 10.1016/j.ejogrb.2010.08.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 07/19/2010] [Accepted: 08/26/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study is to determine the risk factors for rupture of an ectopic pregnancy (EP) to help physicians identify those women who are at greatest risk. STUDY DESIGN The study group comprised the cases of EP treated in our department from January 2003 to September 2009. The following parameters were retrospectively examined: rupture status, past history of pelvic infection or EP, use of an intrauterine device (IUD), parity and gestational age. Women with tubal rupture were compared to those without rupture. Where appropriate, univariate and multivariate analyses were used to identify predictors of the outcome of EP. RESULTS Two hundred and thirty-two cases of EP were retrieved. Eighty-eight of them (37.9%) were cases with ruptured EP and 144 (62.1%) were cases with unruptured EP. No significant associations existed regarding IUD use, smoking, previous ectopic pregnancy, past history of pelvic inflammatory disease (PID) or history of endometriosis. The mean gestation (in weeks) since the last menstrual period and the mean level of βhCG were significantly higher in patients with ruptured EP compared with patients with unruptured EP (7.8 ± 1.09 versus 6.4 ± 1.2, p < 0.0001; and 8735.3 ± 11317.8 IU/ml versus 4506 ± 5673.7 IU/ml, p < 0.0001, respectively). Logistic regression analysis revealed that 6-8 weeks of amenorrhoea (OR: 3.67; 95% CI: 1.60-8.41) and >8 weeks of amenorrhoea (OR: 46.46; 95% CI: 14.20-152.05) and also 1501-5000 IU/ml of βhCG level (OR: 4.11; 95% CI: 1.53-11.01) and >5000 IU/ml of βhCG levels (OR: 4.40; 95% CI: 1.69-11.46) were the significant risk factors for tubal rupture. CONCLUSIONS Higher βhCG levels and higher gestational age seem to be significant risk factors for rupture of an EP.
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Affiliation(s)
- B Pınar Cilesiz Goksedef
- Department of Obstetrics and Gynecology, Haseki Teaching and Research Hospital, Istanbul, Turkey.
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Kirk E, Van Calster B, Condous G, Papageorghiou AT, Gevaert O, Van Huffel S, De Moor B, Timmerman D, Bourne T. Ectopic pregnancy: using the hCG ratio to select women for expectant or medical management. Acta Obstet Gynecol Scand 2011; 90:264-72. [PMID: 21306315 DOI: 10.1111/j.1600-0412.2010.01053.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify variables that can be used to select women with an ectopic pregnancy for expectant or medical management with systemic methotrexate. DESIGN Cohort study. SETTING Early Pregnancy Unit of a London teaching hospital. POPULATION Women with a tubal ectopic pregnancy managed non-surgically. METHODS The diagnosis of tubal ectopic pregnancy was made using transvaginal sonography. Human chorionic gonadotrophin (hCG) levels had to be taken at 0 hour and 48 hours pre-treatment. Other recorded variables include presenting complaints, gestational age, progesterone levels, size of the ectopic mass and appearance of the ectopic on transvaginal sonography. Women were followed up until the outcome (success or failure) of management was known. MAIN OUTCOME MEASURES Univariable analysis was performed to identify the variables associated with successful management using area under curves and relative risks. RESULTS Thirty-nine women underwent expectant management (overall success rate 71.8%) and 42 had medical management (overall success rate 76.2%). The pre-treatment hCG ratio (hCG 48 hours/hCG 0 hour) was related to the failure of both expectant (area under curve 0.86, 95% CI 0.67-0.94) and medical (area under curve 0.79, 95% CI 0.58-0.90) management. History of ectopic pregnancy was related to failure of expectant management only (relative risk 0.46, 95% CI 0.16-0.92). CONCLUSIONS The most important variable for predicting the likelihood of successful non-surgical management was the pre-treatment hCG ratio. New studies are required to validate the use of this variable and of history of ectopic pregnancy to predict the likelihood of successful non-surgical management in clinical practice.
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Affiliation(s)
- Emma Kirk
- Early Pregnancy and Gynaecological Ultrasound Unit, St George's, University of London, UK.
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Doubilet PM, Benson CB. First, do no harm... To early pregnancies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:685-689. [PMID: 20427779 DOI: 10.7863/jum.2010.29.5.685] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Bottomley C, Van Belle V, Mukri F, Kirk E, Van Huffel S, Timmerman D, Bourne T. The optimal timing of an ultrasound scan to assess the location and viability of an early pregnancy. Hum Reprod 2009; 24:1811-7. [DOI: 10.1093/humrep/dep084] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tubal ectopic pregnancy: diagnosis and management. Arch Gynecol Obstet 2008; 279:443-53. [DOI: 10.1007/s00404-008-0731-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 07/08/2008] [Indexed: 12/27/2022]
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Evolución, complicaciones y repercusión económica del embarazo ectópico según algoritmo para su asistencia. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2008. [DOI: 10.1016/s0210-573x(08)73052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
PURPOSE OF REVIEW This review discusses the diagnosis and nonsurgical management of ectopic pregnancy. RECENT FINDINGS In the majority of cases the diagnosis of ectopic pregnancy should be made on transvaginal ultrasonography. Those for which the diagnosis is not made on the first scan may initially be classified as pregnancies of unknown location. There are now a number of strategies and mathematical models to predict ectopic pregnancy in this pregnancy of unknown location population. Reported success rates for expectant and medical management of ectopic pregnancy vary due to different inclusion criteria. A number of predictors of success have been studied: maternal age, previous obstetric history, gestational age, ultrasound features, human chorionic gonadotrophin levels, progesterone levels and the change in human chorionic gonadotrophin over time. At present the initial human chorionic gonadotrophin level probably remains the single most important predictor of success. Nonsurgical management is also particularly important for nontubal ectopic pregnancies: interstitial, cervical and caesarean section scar pregnancies. SUMMARY The majority of ectopic pregnancies can be visualized by ultrasound and so can be considered for conservative treatment. Nonsurgical management can be safe and effective. Appropriate selection criteria remain an issue, however, and a consensus needs to be reached on the predictors of success and failure to optimize management.
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Affiliation(s)
- Emma Kirk
- Early Pregnancy Unit, St George's Hospital, University of London, London, UK.
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Elito Junior J, Camano L. Unruptured tubal pregnancy: different treatments for early and late diagnosis. SAO PAULO MED J 2006; 124:321-4. [PMID: 17322952 PMCID: PMC11068276 DOI: 10.1590/s1516-31802006000600004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 10/06/2006] [Indexed: 12/27/2022] Open
Abstract
CONTEXT AND OBJECTIVE There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. DESIGN AND SETTING Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHODS Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m(2) (body surface area) intramuscularly and 62 were managed expectantly. In this study we evaluated the beta-hCG levels at presentation and amenorrhea duration. RESULTS There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (managed expectantly) had longer amenorrhea (mean: 8.87 +/- 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 +/- 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 +/- 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 +/- 2315.1 mIU/ml). CONCLUSIONS The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48-hour intervals and lower beta-hCG levels requiring expectant management.
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Affiliation(s)
- Julio Elito Junior
- Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
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Fukami T, Emoto M, Tamura R, Kawarabayashi T. Sonographic findings of transvaginal color Doppler ultrasound in ectopic pregnancy. J Med Ultrason (2001) 2006; 33:37-42. [PMID: 27277617 DOI: 10.1007/s10396-005-0064-9] [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: 05/11/2005] [Accepted: 08/19/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of this study was to retrospectively assess whether the sonographic findings from transvaginal color Doppler ultrasound (TV-CDU) are helpful in the diagnosis of ectopic pregnancy. METHODS Thirty-four patients who received surgery for ectopic tubal pregnancies were preoperatively evaluated using TV-CDU. The presence or absence of color vascularity within the ectopic masses was examined. The relationship between the presence or absence of blood flow in the tubal mass and the corpus luteum cyst, or the serum β-hCG values, was evaluated. RESULTS Color vascularity within the adnexal mass was detected in 27 of 34 (79.4%) patients with ectopic pregnancies by TV-CDU. Color vascularity within the mass was observed in 18 of 24 (75.0%) patients with a questionable adnexal mass that had no obvious gestational sac in B-mode images. Moreover, color vascularity was seen in all four patients with a serum β-human chorionic gonadotropin (β-hCG) value of less than 500 mIU/ml. However, it was difficult to identify the blood flow of the adnexal mass in six of the nine (66.7%) patients with a corpus luteum cyst in the ipsilateral ovary. No relationship was observed between the serum β-hCG concentrations and the resistance indices, or the peak systolic velocity. CONCLUSIONS The detection of color vascularity by TV-CDU in patients with an ectopic pregnancy is helpful for diagnosis, especially for patients with either a questionable adnexal mass in B-mode images or lower serum β-hCG concentrations.
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Affiliation(s)
- Tatsuya Fukami
- Department of Obstetrics and Gynecology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Makoto Emoto
- Department of Obstetrics and Gynecology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Riko Tamura
- Department of Obstetrics and Gynecology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Tatsuhiko Kawarabayashi
- Department of Obstetrics and Gynecology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
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Kirk E, Condous G, Bourne T. The non-surgical management of ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 27:91-100. [PMID: 16374758 DOI: 10.1002/uog.2602] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Ectopic pregnancy can now be detected at earlier gestations in asymptomatic women. As a consequence conservative treatment strategies may be more appropriate than surgical intervention. This review aims to discuss the diagnosis and the non-surgical management options for ectopic pregnancy, in particular expectant management and the use of methotrexate.
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Affiliation(s)
- E Kirk
- Early Pregnancy, Gynaecological Ultrasound and MAS Unit, St George's Hospital School, London, UK
| | - G Condous
- Early Pregnancy, Gynaecological Ultrasound and MAS Unit, St George's Hospital School, London, UK
| | - T Bourne
- Early Pregnancy, Gynaecological Ultrasound and MAS Unit, St George's Hospital School, London, UK
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Fernandez H, Gervaise A. Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy. Hum Reprod Update 2004; 10:503-13. [PMID: 15388673 DOI: 10.1093/humupd/dmh043] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ectopic pregnancy (EP) is a major event in a woman's reproductive life. It complicates infertility treatment and must be recognized early to simplify the treatment strategy, which must always be directed towards optimizing subsequent fertility. Epidemiological findings indicate that tubal history and smoking are the principal risk factors of those EP that are considered reproductive (rather than contraceptive) failures. Adding together the attributable risks for EP allows the construction of a risk scale to determine its probability for any given patient. This risk calculation makes it easier to establish a diagnostic strategy that uses abdominal and transvaginal ultrasound and hCG assays. Progesterone assays are useful only for determining the activity of the pregnancy but do not help to identify its site. Conservative treatment is to be preferred unless the EP occurs on a known hydrosalpinx. All the treatment trials and the Cochrane database meta-analysis show that medical treatment with methotrexate, preferably multidose, is equivalent in efficacy to conservative treatment with laparoscopy in the populations studied. Heterotopic pregnancies, which occur most often after assisted reproduction technology (1-3%), should preferably be treated by salpingectomy except in interstitial sites. There is no consensus that IVF is indicated after EP. The patient's age is probably the determining factor: fertility treatment should not be delayed to an age where the results would be altered, especially with the risk of a recurrent EP.
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Affiliation(s)
- Herve Fernandez
- Service de Gynécologie Obstetrique du Professeur René Frydman, Hôpital Antoine Béclère, Paris, France.
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Abstract
In a pregnant woman who presents with acute pelvic pain and an adnexal mass, pregnancy-related etiologies, such as ectopic pregnancy or ovarian torsion, are typically the first diagnoses to be considered. Many other causes of pelvic pain associated with an adnexal mass can occur in pregnant patients, however. Some causes are benign and others require urgent management and treatment. Clinical presentation and physical examination can be misleading in pregnancy. The location of pain may be atypical for the pathologic entity, the pain may be muted, and in the case of infection, fever and leukocytosis can be absent. US examination is a safe and effective method for evaluating these patients. Sonographic characterization of adnexal masses may make a definitive diagnosis or focus the differential, which allows for prompt and appropriate treatment of patients.
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Affiliation(s)
- Emily M Webb
- Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
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Atri M. Ectopic pregnancy versus corpus luteum cyst revisited: best Doppler predictors. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2003; 22:1181-1184. [PMID: 14620888 DOI: 10.7863/jum.2003.22.11.1181] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To determine the best Doppler values for differentiating ectopic pregnancy from a corpus luteum cyst of pregnancy. METHODS This was a prospective study of 80 consecutive patients with the diagnosis of ectopic pregnancy. All ectopic pregnancies were diagnosed on the basis of the presence of an extra-ovarian adnexal mass on sonography and were confirmed surgically. The last menstrual period ranged from 4 to 11 weeks (mean, 6.3 weeks), and the maximal ectopic pregnancy diameter ranged from 0.7 to 5.5 cm (mean, 2.5 cm). Seventy-six ectopic pregnancies showed color vascularity, and 40 showed corpus luteum cysts with vascular walls. The highest peak systolic velocity and the lowest resistive index of the vascular ectopic pregnancies were compared with the corresponding values in the vascular corpus luteum cysts. RESULTS The mean peak systolic velocity of the ectopic pregnancies was 35.4 cm/s compared with 28.4 cm/s in corpus luteum cysts, with no significant statistical difference (P = .1). The resistive index of the ectopic pregnancies ranged from 0.15 to 1.6 (mean +/- SD, 0.61 +/- 0.24) compared with 0.39 to 0.7 (mean, 0.52 +/- 0.10) in corpus luteum cysts, with a significant statistical difference (P = .003). In this cohort, a resistive index of less than 0.39 had a specificity of 100% and a positive predictive value of 100% for diagnosing ectopic pregnancy but was present in only 15% (confidence interval, 7%-23%) of ectopic pregnancies. A resistive index of greater than 0.7 had a specificity of 100% and a positive predictive value of 100% for diagnosing ectopic pregnancy and was present in 31% (confidence interval, 21%-41%) of ectopic pregnancies. CONCLUSIONS Both low and high resistive indices discriminate ectopic pregnancy from a corpus luteum cyst.
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Affiliation(s)
- Mostafa Atri
- Department of Radiology, McGill University Montreal General Hospital, Montreal, Quebec, Canada.
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Abstract
There are several advantages to ultrasound examination in early pregnancy. Ultrasound performed during the first trimester confirms an intrauterine pregnancy, establishes accurate dating, and is crucial in diagnosing early pregnancy failure and ectopic pregnancy. As sonographic spatial resolution continues to improve, first trimester sonography increasingly will offer early pregnancy screening for chromosomal abnormalities and fetal structural abnormalities.
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Affiliation(s)
- Elizabeth Lazarus
- Department of Diagnostic Radiology, Brown Medical School, 593 Eddy Street, Providence, RI 02903, USA.
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Abstract
Ultrasound is the most valuable imaging modality in evaluating the premenopausal female presenting with acute pelvic pain. The appropriate interpretation of the ultrasound study requires correlation with the patient's clinical history and laboratory values. This is especially true of the serum beta-hCG, where ultrasound relies on this test to make the diagnosis of ectopic pregnancy. When the serum test for pregnancy is negative and the patient has an adnexal mass this could be secondary to a complicated ovarian cyst (hemorrhage, rupture), ovarian torsion or pelvic inflammatory disease. The ultrasound image can usually make the diagnosis in conjunction with the clinical papameters, however, this is most difficult in patients with ovarian torsion.
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Affiliation(s)
- Elizabeth A Ignacio
- Department of Radiology, The George Washington University Hospital, Washington, DC 20037, USA
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Szabó I, Csabay L, Belics Z, Fekete T, Papp Z. Assessment of uterine circulation in ectopic pregnancy by transvaginal color Doppler. Eur J Obstet Gynecol Reprod Biol 2003; 106:203-8. [PMID: 12551793 DOI: 10.1016/s0301-2115(02)00235-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of our study was to determine the effect of abnormal implantation on uterine circulation and to evaluate whether the assessment of uterinal blood flow can provide additional information for the diagnosis of tubal pregnancies. METHODS Forty-nine patients with ectopic pregnancy were examined by transvaginal color Doppler immediately before surgery. Resistance and pulsatility indices of blood flow in the uterine and tubal arteries were measured. RESULTS The blood flow parameters of the uterine and tubal arteries did not change with gestational age. There was a significant increase in blood flow on the side with the tubal gestation. Differences between sides were higher in the tubal arteries than in the main uterine arteries and showed no dependence on gestational age. CONCLUSION The abnormal implantation and tubal trophoblast invasion in ectopic pregnancy (EP) can cause more marked blood flow changes in the adjacent supplying vessels than in the main uterine arteries.
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Affiliation(s)
- István Szabó
- First Department of Obstetrics and Gynecology, Semmelweis University, Baross Utca 27, P.O. Box 104, H-1442, Budapest, Hungary.
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Horn LC, Faber R, Meiner A, Piskazeck U, Spranger J. Current awareness in prenatal diagnosis. Prenat Diagn 2001; 21:427-33. [PMID: 11360293 DOI: 10.1002/pd.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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