Temporal trends in severe morbidity and mortality associated with ectopic pregnancy requiring hospitalisation in Washington State, USA: a population-based study

OBJECTIVE

To examine temporal trend in maternal mortality/severe morbidity associated with hospitalisation due to ectopic pregnancy.

DESIGN

A population-based observational study.

SETTING AND PARTICIPANTS

All women hospitalised for ectopic pregnancy in Washington State, USA, 1987-2014 (n=20 418). The main composite outcome of severe morbidity/mortality included death, sepsis, need for transfusion, hysterectomy and systemic or organ failure, identified by diagnostic and procedure codes from hospitalisation files. Severe morbidity/mortality due to ectopic pregnancy were expressed as incidence ratios among women of reproductive age (15-64 years) and among women hospitalised for ectopic pregnancy. Comparisons were made between 1987-1991 (reference) and 2010-2014 using ratios of incidence ratios (RR) and ratio differences (RD). The Cochran-Armitage test for trend assessed statistical significance; logistic regression was used to obtain adjusted OR (AOR) and 95% CI, adjusted for demographic factors and comorbidity.

RESULTS

Hospitalisation for ectopic pregnancy declined from 0.89 to 0.16 per 1000 reproductive age women between 1987-1991 and 2010-2014 (p<0.001). Among reproductive age women, ectopic pregnancy mortality remained stable (0.03 per 100 000); and mortality/severe morbidity increased among women aged 25-34 years (p=0.022). Among women hospitalised for ectopic pregnancy, mortality increased from 0.29 to 1.65 per 1000 between 1987-1991 and 2010-2015 (p=0.06); severe morbidity/mortality increased from 3.85% to 19.63% (RR=5.10, 95% CI 4.36 to 5.98; RD=15.78 per 100 women, 95% CI 13.90 to 17.66; AOR for 1-year change was 1.08, 95% CI 1.07 to 1.08).

CONCLUSIONS

Hospitalisation for ectopic pregnancy declined in Washington State, USA, between 1987 and 2014; however, mortality/severe morbidity associated with ectopic pregnancy increased in female population aged 25-34 years.

Institutional maternal and perinatal deaths: a review of 40 low and middle income countries

BACKGROUND

Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates.

METHODS

This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel.

RESULTS

Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth.

CONCLUSIONS

To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.

Abnormal implantation after fresh and frozen in vitro fertilization cycles

OBJECTIVE

To determine whether fresh embryo transfers are at a higher risk of abnormal implantation compared with frozen embryo transfers while accounting for the embryo stage at transfer.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

We used data from the Society for Assisted Reproductive Technologies to identify all fresh and frozen autologous IVF cycles from 2004-2013 resulting in a positive pregnancy test. The cycles were parameterized into a four-level predictor of [1] fresh blastocyst transfer, [2] fresh non-blastocyst transfer, [3] frozen blastocyst transfer, and [4] frozen non-blastocyst transfer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

We examined a composite outcome of abnormal implantation, defined as biochemical pregnancy, ectopic/heterotopic pregnancy, and first-trimester pregnancy loss. Regression modeling was performed with repeated measures multivariable logistic regression, adjusted for age, parity, number of embryos transferred, infertility diagnosis, and calendar year of treatment.

RESULT(S)

Of 509,938 cycles analyzed, 31.8% resulted in abnormal implantation. Compared with a fresh blastocyst transfer, a fresh non-blastocyst transfer had a 22% increase risk of abnormal implantation, a frozen blastocyst transfer had a 36% increase risk, and a frozen non-blastocyst transfer had a 57% increase risk. When individual outcomes were analyzed, fresh embryo transfers had a lower risk of biochemical pregnancy and pregnancy loss but a higher risk for ectopic/heterotopic pregnancy.

CONCLUSION(S)

Fresh blastocyst transfers had the lowest overall risk of abnormal implantation but a higher risk of ectopic/heterotopic pregnancy. Although embryo cryopreservation is indicated in certain treatment cycles, elective embryo cryopreservation may not be the optimal strategy to adopt for all cycles.

[Main causes of maternal mortality in Mexicali, Baja California (Mexico)]

OBJECTIVE

The objective of this study is to determine the main causes of maternal mortality in the period 2009 to 2013 in Mexicali, Baja California, Mexico.

MATERIAL AND METHODS

Epidemiological, observational, descriptive, cross-sectional, and retrospective study was conducted with a universe of 30 cases of maternal death. The information was collected from death certificates and records of cases obtained from the Institute of State Public Service Health of University Xochicalco.

RESULTS

The average age of patients were 26.6 ± 5.6 years. Educational level and marital status was with junior school 15 (50%) and free union 12 (40%) respectively, 21 (70%) had no prenatal care. The mean gestational age was 28.8 ± 3.72 weeks, there was no difference in the place of residence, urban and rural, 15(50%). The main cause of death was hemorrhage 9(30%). The highest mortality was during the postpartum period 23 (77%). During the study period, the mortality rate was 36.8 x 100,000 live births.

CONCLUSIONS

The increased frequency of maternal mortality was in young women, 70% had no prenatal care. Bleeding from ectopic pregnancy was the leading cause of death.

A five year review of ectopic pregnancy at Federal Medical Centre, Owerri, South East, Nigeria

BACKGROUND

Ectopic pregnancy remains a leading cause of maternal morbidity and mortality in the first trimester of pregnancy in developing countries.

OBJECTIVES

To determine the incidence, pattern of presentation and management of ectopic pregnancies at Federal Medical Centre (FMC) Owerri.

METHODS

This was a retrospective descriptive study of all cases of ectopic gestations managed at FMC Owerri between 1st January 2009 and 31st December, 2013. The case notes were retrieved from the hospital's Records Department and information on socio-demographic characteristics, age, and parity, clinical presentation, findings at laparotomy, estimated blood loss and the need for blood transfusion were obtained. Data were entered into SPSS 17.0 and analysed descriptively.

RESULTS

There were 382 cases of ectopic gestations out of the total 9880 total deliveries within the study period. The incidence of ectopic pregnancy was 38.66 per 1,000 live births or I in 26 deliveries. Nulliparous women were 132 (34.5%). At presentation, 99.47% of patients had rupture with haemoperitoneum, with the commonest site being the ampulla of the fallopian tube as seen in 338 (88.4%). Salpingectomy was done in majority of cases, accounting for 355 (93%), while 248 (65%) had blood transfusion. Five (1.3%) maternal deaths occurred during period of study.

CONCLUSION

Ectopic pregnancy presents a major public health challenge among women of reproductive age groups in Nigeria. Efforts should be directed to public awareness on sex education, contraception, prevention and treatment of common risk factors for ectopic pregnancy.

Pregnancy related causes of deaths in Ghana: a 5-year retrospective study

OBJECTIVE

Data on maternal mortality varies by region and data source. Accurate local-level data are essential to appreciate its burden. This study uses autopsy results to assess maternal mortality causes in southern Ghana.

METHODS

Autopsy log books of the Department of Pathology, Korle-Bu Teaching Hospital Mortuary were reviewed from 2004 through 2008 for pregnancy related deaths. Data were entered into a database and analyzed using SPSS statistical software (Version 19).

RESULTS

Of 5,247 deaths among women aged 15-49, 12.1% (634) were pregnancy-related. Eighty one percent of pregnancy-related deaths (517) occurred in the community or within 24 hours of admission to a health facility and 18.5% (117) occurred in a health facility. Out of 634 pregnancy-related deaths, 79.5% (504) resulted from direct obstetric causes, including: haemorrhage (21.8%), abortion (20.8%), hypertensive disorders (19.4%), ectopic gestation (8.7%), uterine rupture (4.3%) and genital tract sepsis (2.5%). The remaining 20.5% (130) resulted from indirect obstetric causes, including: infections outside the genital tract, (9.2%), anemia (2.8%), sickle cell disease (2.7%), pulmonary embolism (1.9%) and disseminated intravascular coagulation (1.3%). The top five causes of maternal death were: haemorrhage (21.8%), abortion (20.7%), hypertensive disorders (19.4%), infections (9.1%) and ectopic gestation (8.7%).

CONCLUSION

Ghana continues to have persistently high levels of preventable causes of maternal deaths. Community based studies, on maternal mortality are urgently needed in Ghana, since our autopsy studies indicates that 81% of deaths recorded in this study occurred in the community or within 24 hours of admission to a health facility.

Early pregnancy failure: beware of the pitfalls of modern management

The evolution of the diagnosis and management of women with an early pregnancy loss has been a success story. The mortality from ectopic pregnancy has objectively been decreased in the past few decades. However, modern management has resulted in a new set of issues. Over-interpretation of a single ultrasound, misunderstanding of the utility of serial hCG values, and inappropriate use of methotrexate can result in iatrogenic complications. Modern management has successfully improved the diagnosis of ectopic pregnancy before rupture; it should now also focus on ensuring that an intrauterine pregnancy is not interrupted as a result of diagnosis and treatment. This article reviews some of the pitfalls of the modern management of early pregnancy failure and introduces a series of articles on the subject.

Centers for Disease Control and Prevention (CDC). Ectopic pregnancy mortality - Florida, 2009-2010

Ectopic pregnancy occurs when a fertilized ovum implants on any tissue other than the endometrial lining of the uterus. Approximately 1%-2% of pregnancies in the United States are ectopic; however, these pregnancies account for 3%-4% of pregnancy-related deaths. The ectopic pregnancy mortality ratio in the United States decreased from 1.15 deaths per 100,000 live births in 1980-1984 to 0.50 in 2003-2007. During 1999-2008, the ectopic pregnancy mortality ratio in Florida was similar to the national rate, 0.6 deaths per 100,000 live births, but increased abruptly to 2.5 during 2009-2010. Florida's Pregnancy-Associated Mortality Review (PAMR) identified ectopic pregnancy deaths during 1999-2010 through its routine process of identifying all pregnancy-related deaths. A multidisciplinary investigation committee reviewed the ectopic pregnancy deaths for cause of death, risk factors, and prevention opportunities. This report summarizes the investigation results, which identified 11 ectopic pregnancy deaths from 2009-2010 and 13 deaths from the 10-year period 1999-2008. The increase in ectopic mortality appears to be associated with illicit drug use and delays in seeking health care. The findings underscore the importance of ongoing, state-based identification and review of pregnancy-related deaths. Such reviews have the potential to identify emerging causes of deaths and associated risk factors, such as ectopic pregnancy deaths among women who use illicit drugs. Efforts to prevent ectopic pregnancy deaths need to ensure early access to care, promote awareness about early pregnancy testing and ectopic pregnancy risk, and raise public awareness about substance abuse health risks, especially during pregnancy.

[Analysis of maternal deaths in Shanghai from 2000 to 2009]

OBJECTIVES

To find problems in the systematic management of maternal health and to provide evidence for developing effective interventions to reduce maternal mortality in Shanghai.

METHODS

Every maternal death from 2000 to 2009 was audited by experts and relevant informations were collected and analyzed retrospectively.

RESULTS

(1) Number of live births. The number of live births in Shanghai rised from 84 898 in 2000 to 187 335 in 2009, which increased by 120.7%. Notably, the number of live births of migrating people increased 4.6 times. In 2000, it took up 25.5% and in 2009, it rose to 54.8%. (2) Maternal mortality ratio (MMR) and its composition. The total live births from 2000 to 2009 was 1 279 010, among which there were 262 maternal deaths, with average maternal mortality of 20.48 per 100,000 live birth (262/1,279,010). For Shanghai residents, the MMR was 8.09 per 100,000 live births (55/680,005), while the MMR of migrating people was 34.56 per 100,000 live births (207/599,005). (3) Trends of MMR. The MMR declined from 21.2 per 100,000 live births in 2000 to 9.61 per 100,000 live births in 2009. The MMR of Shanghai residents maintained below 10 per 100,000 live births with exception of year 2003 and 2004. The MMR of migrating people declined sharply. In 2002 it was 77.42 per 100,000 live births, and in 2009 it decreased to 11.69 per 100,000 live births. (4) The composition of causes of maternal deaths and rank order. The top 5 causes of deaths were obstetric hemorrhage (69 cases, 26.3% of the total deaths), pregnancy induced hypertension (27 cases, 10.3% of the total deaths), heart diseases (24 cases, 9.2% of the total deaths), liver diseases (17 cases, 6.5% of the total deaths), amniotic fluid embolism and ectopic pregnancy (15 cases respectively, 5.7% of the total deaths). (5) The changes of causes between the first 5 years and the latter 5 years. The MMR of ectopic pregnancy, heart diseases and pregnancy induced hypertension changed significantly in Shanghai residents. The MMR of ectopic pregnancy decreased from 1.36 per 100,000 live births in the first 5 years to 0.26 per 100,000 live births in the latter 5 years. The MMR of heart diseases decreased from 1.36 per 100,000 live births to 0.52 per 100,000 live births. While the MMR of pregnancy induced hypertension increased from 0 to 0.78 per 100,000 live births. For migrating population, the MMR of obstetric hemorrhage, ectopic pregnancy and pregnancy induced pregnancy deceased significantly. As the primary cause, the MMR of obstetric hemorrhage deceased from 21.85 per 100,000 live births in the first 5 years to 5.47 per 100,000 live births in the second 5 years. The MMR of ectopic pregnancy decreased from 4.37 per 100,000 live births to 0.68 per 100,000 live births. And the MMR of pregnancy induced hypertension decreased from 6.87 per 100,000 live births to 2.96 per 100,000 live births. (6) Direct obstetric causes and indirect obstetric causes of maternal deaths. Among the 262 deaths, 141 cases (53.8%) were due to Direct obstetric causes and 121 (46.2%) were due to indirect obstetric causes. (7) The trend of MMR of obstetric hemorrhage. The MMR of obstetric hemorrhage declined from 10.6 per 100,000 live births in 2000 to 1.7 per 100,000 live births in 2009. (8) The results of maternal death audit. The results of maternal death audit were classified into 3 categories: 41 cases (15.6%) belonged to the first category, i.e, avoidable deaths; 66 cases (25.2%) belonged to the second category, i.e, avoidable when creating some conditions; and 155 cases (59.2%) belonged to the third category, which means not avoidable. Among 55 deaths of Shanghai residents, 17 cases (30.9%) belonged to the first category, 14 cases (25.5%) belonged to the second, and 24 cases (43.6%) belonged to the third category. Among 207 deaths of migrating population, 24 cases (11.6%) belonged to the first category, 52 cases (25.1%) belonged to the second, and 131 cases (63.3%) belonged to the third category. (9) WHO twelve-grid classification of maternal deaths. The factors, including attitude, knowledge and skills, resources and management of the dead people and their families, the medical institutes and social supportive departments were integrated and analyzed. It showed that the main reason of maternal deaths of Shanghai residents was poor knowledge and skills of medical staffs, accounting for 80.0% of the deaths. While the main reasons of maternal deaths of migrating people were poor knowledge and skills, inappropriate attitude of the dead people and their families, which took up 54.1% and 40.1% respectively.

CONCLUSIONS

The MMR in Shanghai declined continuously from 2000 to 2009, especially for migrating population which reflected the interventions of maternal management in Shanghai were effective. Though obstetric hemorrhage was the first top cause of maternal death during past 10 years, it declined Sharply. 30% to 40% maternal deaths were avoidable if some conditions were created. However, in order to adapt the changes of main causes of maternal deaths and accomplish increasing service requirements, it is necessary to develop new service and management mode.

Ectopic pregnancy--an analysis of 180 cases

Ectopic pregnancy is the most life threatening emergency in pregnancy. Increase in incidence and impairment in fertility are now the real concerns. The aim of this study was to estimate the epidemiological, diagnostic and therapeutic aspects of ectopic pregnancy with a view to suggest action to improve the prognosis. This was a prospective study carried out at NRS Medical College, Kolkata, among consecutive 180 patients of ectopic pregnancy admitted from January, 2002 to December, 2004. During this period the incidence of ectopic pregnancy was 1 in 161(0.6%). The peak age of incidence was 26-30 years; primi were the most sufferers. There were 65.0% patients was had identifiable risk factors. Tubectomy (14.4%), history of abortion (26.1%), infertility (12.2%), pelvic inflammatory diseases (12.8%) and history of previous surgery (11.1%) were the important risk factors. Amenorrhoea (76.1%), abdominal pain (86.1%) and vaginal bleeding (42.2%) were the frequent presenting complaints. There were 87.8% patients was had pallor, 9.4% were admitted with features of shock. Cervical motion tenderness (82.2%) was the most frequent sign. Urinary beta-hCG was positive in 96.1% cases. Ultrasonography revealed diagnosis in 2/3rds cases among 129 patients. Culdocentesis evoked the diagnosis in 73.3% cases out of 135 patients. In 95.0% cases it was of tubal variety, 70.2% ruptured, 19.9% tubal abortion and 9.9% unruptured. Surgery by open method in the form of salpingectomy (81.9%), salpingo-oophorectomy (9.3%) and salpingostomy (5.3%) were the mainstay of management. Expectant management and medical therapy can be offered only in 1.2% and 1.75% respectively. There was no case fatality. By reducing and identifying the risk factors and 'catching' the patients at the earliest it is possible to improve the prognosis so far as morbidity, mortality and fertility are concerned.

Prise en charge de la grossesse extra-utérine dans les pays en voie de développement : exemple d'une maternité de référence au Niger

OBJECTIVE

We report 143 cases of ectopic pregnancy (EP) treated in the Issaka-Gazobi maternity of Niamey between January 1st, 1999 and April 30th, 2001 (28 months). The objective of this study was to estimate the epidemiological, diagnostic and therapeutic aspects to propose actions, which could lead to the improvement of the prognosis of EP.

PATIENTS AND METHODS

The frequency of ectopic pregnancy was 2.32% in our study. The patients were young and pregnant for the second or third time. Frequently we observed previous sexually contagious infections and/or abortions. More than 70% of the patients were admitted for a complicated stage of EP.

RESULTS

The culdocentesis allowed to evoke the diagnosis in more than 80% of the cases. It is a simple gesture, which makes it possible to make the diagnosis of EP and which should be taught and practised in maternities of the developing countries. The pelvic ultrasonography and the laparoscopy allowed the diagnosis in the other cases. The tubal localization was the most frequent, cervical and abdominal pregnancies were found. The surgical treatment conducted by laparotomy was conservative in 11.9% and radical in 87.4% of the cases. The mortality rate was still 0.70%.

DISCUSSION AND CONCLUSION

Prevention of the sexually contagious infections and medical management of abortions are important to reduce the risks of ectopic pregnancies. Education of the patients, living far from the maternity, is also necessary to obtain more precocious consultation in case of pregnancy in order to improve the prognosis of EP.

Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999

The comparative safety of pregnancy outcomes has clinical and public health importance. Using national statistics for 1991 to 1999, I estimated the risk of maternal death associated with various outcomes. Abortion (legal and spontaneous) was associated with the lowest risk, live birth intermediate risk, and ectopic pregnancy and fetal death the highest risk.

Ectopic pregnancy deaths: what should we be doing?

Ectopic pregnancy is the leading cause of maternal mortality in the first trimester of pregnancy. A greater awareness of risk factors and improved diagnostic techniques now allow ectopic pregnancies to be identified before the development of life-threatening events. Non-surgical management options also decrease maternal morbidity.

Maternal mortality in Australia, 1973-1996

AIMS

Maternal mortality has declined dramatically over the past 30 years in developed countries. This retrospective study aims to provide an epidemiological overview of maternal deaths in Australia between 1973 and 1996.

METHODS

Data were abstracted from national maternal mortality data collection and triennial reports for the period 1973-1996 for women who died from pregnancy-related causes while pregnant or within 42 days of a pregnancy being delivered or terminated. Deaths were restricted to those classified as direct or indirect maternal deaths. Maternal mortality age-specific mortality ratios were calculated. The leading causes of death were examined.

RESULTS

Of the 584 deaths, 363 were direct and 221 indirect. The leading causes of direct death were pulmonary embolism (18.4%) and hypertensive disorders (16.3%). Cardiovascular disease accounted for 41% of indirect deaths. The maternal mortality ratio declined from 12.7 deaths per 100,000 confinements in 1973-1975 to 6.2 in 1991-1993, and was 10.0 for the entire 24-year period. For women aged 40-44 years the ratio declined from 165.1 to 14.2 between 1973 and 1996. The ratio for Indigenous mothers was three times higher than for non-Indigenous mothers, being 34.8 in the most recent triennium 1994-1996.

CONCLUSIONS

Although maternal deaths are rare in Australia, apparent health inequality persists with Indigenous mothers continuing to have a higher risk of maternal death. While mortality in traditionally higher risk women aged > 40 years has declined, women with morbid cardiovascular disease continue to be over-represented in the deaths. The comparatively high rate of deaths from pulmonary embolism needs to be addressed.

Sudden Death: Ectopic Pregnancy Mortality

OBJECTIVE

To describe the trends in ectopic pregnancy mortality in Michigan from 1985 through 1999 and compare to those of previous time periods.

METHODS

We reviewed all cases of maternal mortality from ectopic pregnancy in Michigan from 1985 through 1999. We extracted data from death certificates, hospital inpatient and emergency department records, medical examiner autopsy reports, and reviews by the Michigan Maternal Mortality Study. The Health Data Development Section of the Michigan Department of Community Health provided data on live births and maternal deaths

RESULTS

Of the 268 pregnancy-related deaths, 16 (6%) were caused by complications of ectopic pregnancy. Mean age at death was 27 (+/- 6) years. Thirteen deaths were to African-American women and 3 were to white women (P < .01). African-American women had an ectopic mortality ratio 18 times higher than white women (3.25/100,000 live births, compared with 0.18/100,000) Three cases of pregnancy-related death due to complications of ectopic pregnancy were considered preventable, and 2 others were of unknown preventability.

CONCLUSION

Ectopic pregnancy treatment has changed in the last 20 years coincident with a decrease in maternal mortality from ectopic pregnancy. Sudden death was the presenting scenario in 75% of nonpreventable ectopic deaths, an increase from previous analyses. A large racial disparity is apparent. Ideally, pregnancy care should start as soon as possible after the first missed menses; however, systemwide changes are needed to create a new norm promoting early access to pregnancy care and promoting education and testing to rule out pregnancy abnormalities.

LEVEL OF EVIDENCE

II-2

Pregnancy-associated mortality after birth, spontaneous abortion, or induced abortion in Finland, 1987-2000

OBJECTIVE

To test the hypothesis that pregnant and recently pregnant women enjoy a "healthy pregnant women effect," we compared the all natural cause mortality rates for women who were pregnant or within 1 year of pregnancy termination with all other women of reproductive age.

STUDY DESIGN

This is a population-based, retrospective cohort study from Finland for a 14-year period, 1987 to 2000. Information on all deaths of women aged 15 to 49 years in Finland (n=15,823) was received from the Cause-of-Death Register and linked to the Medical Birth Register (n=865,988 live births and stillbirths), the Register on Induced Abortions (n=156,789 induced abortions), and the Hospital Discharge Register (n=118,490 spontaneous abortions) to identify pregnancy-associated deaths (n=419).

RESULTS

The age-adjusted mortality rate for women during pregnancy and within 1 year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women, 57.0 per 100,000 person-years (relative risk [RR] 0.64, 95% CI 0.58-0.71). The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000). We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15 to 24 years (RR 4.08, 95% CI 1.58-10.55).

CONCLUSION

Our study supports the healthy pregnant woman effect for all pregnancies, including those not ending in births.

Autotransfusion for ruptured ectopic pregnancy

OBJECTIVES

Clinical outcomes following the exclusive use of autotransfusion in the management of ruptured ectopic pregnancy are reviewed.

METHODS

A MEDLINE search (1966-2002) for relevant articles documenting the exclusive use of autotransfusion, and data collection and analysis was made.

RESULTS

There were 21 studies, 16 from developing and five from developed countries, involving 632 cases of ruptured ectopic pregnancies. Hypovolemic shock with significant hemoperitoneum (>500 ml) was the most common complication. The procedure was performed completely manually in developing countries and with the help of a device in developed countries. The mean volume of autotransfused blood was over 1000 ml, with mean hemoglobin levels ranging from 6 to 12.5 g/dl. Mean posttransfusion hemoglobin levels were higher than pretransfusion levels. There was one death, thought to be due to pulmonary embolism, and nine major and minor complications.

CONCLUSIONS

Autotransfusion is useful in the management of ruptured ectopic pregnancy.

Mortality and morbidity associated with misdiagnosis of ectopic pregnancy in a defined Nigerian population

Ectopic pregnancies can be very difficult to diagnose at initial admission. This paper reviewed the morbidity and mortality associated with misdiagnosis of ectopic gestation over a 15-year period (1985-99) at Ile-Ife, Nigeria. There were 380 confirmed ectopic pregnancies of 35 857 live births, giving an incidence of 10.5 per 1000 live births. Of the 380 cases, 38 (10%) were misdiagnosed initially at presentation. Mistaken diagnoses include pelvic inflammatory diseases, cholera, acute appendicitis, typhoid enteritis, incomplete septic abortion, uterine fibroid with menorrhagia, malaria, gastroenteritis, peptic ulcer and intestinal obstruction. There were five maternal deaths among the 38 misdiagnosed cases compared to two maternal deaths among the 342 initially correctly diagnosed cases. Significant morbidity included prolonged hospital stay, increased hospital costs and an enterocutaneous fistula. To improve the chances of correct diagnosis at initial admission, accurate menstrual and sexual history should be obtained. Facilities for improved diagnosis such as serum beta HCG and transvaginal ultrasonography should be provided. Colleagues from other specialities should be educated to increase their suspicion of ectopic pregnancy in any woman of childbearing age and perform the appropriate investigations.

Rudimentary uterine horn pregnancy. The 20th-century worldwide experience of 588 cases

OBJECTIVE

To investigate the outcomes of rudimentary uterine horn pregnancies and to identify trends and opportunities for improvement in patient care.

STUDY DESIGN

During the period 1900-1999, 588 cases of rudimentary uterine horn pregnancy were identified using both manual and computerized searches of Index Medicus, Excerpta Medica and the Index-Catalogue of the Library of the Surgeon-General's Office of the United States Army as well as standard reference tracing. Nine characteristics of each case were evaluated: (1) fetal status at birth, (2) maternal survival, (3) neonatal survival, (4) gestational age at delivery, (5) whether the rudimentary horn ruptured, (6) communication status of the horn with the contralateral hemiuterus, (7) gravidity and parity, (8) side of the horn, and (9) order of the gestation.

RESULTS

Newborn survival ranged from 0-13% by decade and trended upward. Eighty-five percent of pregnancies occupied noncommunicating horns. Thirty percent of gestations progressed to term or beyond. Fifty percent of pregnant uterine horns ruptured, with 80% of these events occurring before the third trimester. There was no trend in either the incidence or timing of uterine horn rupture during the century. Maternal mortality decreased from 6% to 23% during the first half of the century to < 0.5% currently. Twin pregnancies consisted of 5.3% of cases.

CONCLUSION

Neonatal survival has improved greatly for rudimentary horn pregnancies, and maternal mortality has decreased significantly. Such pregnancies are now identifiable early in gestation by obstetric imaging studies, and there can be guarded optimism that favorable trends in outcomes will continue into the 21st century.

Ectopic pregnancies: a three year study

OBJECTIVE

To analyze the risk factors and assess the results of management with respect to maternal morbidity and mortality of ectopic pregnancy during the last three years.

SETTING

Ziauddin Medical University Hospital, North Nazimabad campus (ZMUH), Karachi.

RESULTS

Forty-three patients were admitted with ectopic pregnancy at ZMUH from 1st January 1997 to 31st December 1999. Frequency of ectopic pregnancy was 1.3% of total 3252 pregnancies. Risk factors were found in 33% of cases. There was one case of heterotopic pregnancy. Surgical treatment was performed in 36 cases. Two patients were given intramuscular methotrexate and one un-ruptured ectopic resolved after expectant management.

CONCLUSION

Conservative management was an option but surgical treatment was done more often because of late referrals. Screening of high risk cases, early diagnosis and early intervention would reduce the morbidity in ectopic pregnancies.

Laparoscopic sterilization

Laparoscopic female sterilization is still the leading method of family planning for patients who have completed their family. Mechanical methods include clips and rings and are preferred because they are safe and efficient and can be used on a day case basis. Appropriate training ensures improved results with fewer complications. Clips and rings have an improved reversal potential.

A systematic review of single-dose intramuscular methotrexate for the treatment of ectopic pregnancy

The use of single-dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side-effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side-effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single-dose intramuscular methotrexate is associated with a high failure rate. Follow-up is prolonged and there is a significant incidence of minor side-effects. Serious complications and side-effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.

[Incidence and mortality of extrauterine pregnancy in Hungary (1931-1995)]

The authors report on the changing incidence of and maternal mortality from ectopic pregnancies in Hungary between 1931 and 1995. Data of reported pregnancies were obtained from the National Institute of Statistics and the Hungarian College of Obstetricians and Gynecologists. Incidence of ectopic pregnancy was calculated as rates per 1000 live births and per 1000 reported pregnancies including live births, legally induced abortions, miscarriages, and ectopic pregnancies. Ectopic pregnancy-associated maternal mortality was examined in terms of case fatality rate and also as a proportion to the total number of pregnancy-associated maternal deaths. From 1931, when national surveillance for pregnancy begun in Hungary, to 1995, the rate per 1000 reported live births tripled from 3.4 to 11.9. Similarly, the rate of ectopic pregnancies per 1000 reported pregnancies increased by 190% from 3.7 to 6.4. In the last decade of the period studied, its proportion in the annual number of fetal deaths increased to 8.0%. Ectopic pregnancy-associated maternal deaths decreased sharply from 1931 through the late 1980's. In the last decade, its average value was 16 per 10.000 reported ectopic pregnancies. However, case fatality rate of ectopic pregnancy is still highest compared to any of the other obstetric events including induced and spontaneous abortions, and deliveries. Over the last decade, maternal deaths resulting from ectopic gestation represented 8.7% of the total maternal mortality rate. Given the increasing incidence of ectopic pregnancy together with a substantial proportion in pregnancy-related maternal mortality, study of etiology, and appropriate preventive measures are urgently needed.

[Intervention approach and its effect on lowering mortality of ectopic pregnancy in Shanghai]

OBJECTIVE

To explore an effective intervention approach to lower the mortality of ectopic pregnancy.

METHODS

We monitored the mortality of ectopic pregnancy during 1987-1995 in Shanghai and experts' audit, focusing on the causes of death from ectopic pregnancy and combining official administration with intervention approach in medical institutions.

RESULTS

Misdiagnosis and patient's delay to hospital were the causes of death from ectopic pregnancy. There were 523,299 live births in Shanghai from 1987 to 1989, in which 23 cases died from ectopic pregnancy, with a mortality of 4.40/100,000. After implementing the intervention approach, during 1990-1995, 14 cases of the total 625,206 nancies live birth died from ectopic pregnancy, with a mortality of 2.24/100,000, as compared the two, P < 0.05. Accordingly, ectopic pregnancy as the cause of maternal death dropped from the first leading cause to the fourth.

CONCLUSION

Intensive health care education in masses, medical staffs' awareness to ectopic pregnancy, and intervention, early hospitalization, early diagnosis and early therapy can lower the mortality of ectopic pregnancy.

[Ectopic pregnancy. The "epidemic" seems to be over]

Since decades the incidence of ectopic pregnancy has risen in most western countries including four to five folded increased rates, suggesting an "epidemic". Increasing incidences of ectopic pregnancy was reported in Sweden until 1988 and 1989 when a peak of 17.3 cases of ectopic pregnancy/10,000 women in fertile age was registered. Between 1990 and 1991 the incidence decreased from 16.8 to 14.9 cases of ectopic pregnancy/10,000 women. The mortality in Sweden 1985-1991 was 0.15/1000 (3 deaths in 20,486 cases of ectopic pregnancy), the lowest case-fatality rate ever reported.

Ectopic pregnancy: a nursing approach to excess risk among minority women

Ectopic pregnancy rates have quadrupled during the last decade. Although maternal mortality has been reduced for white women, largely because of rapid pregnancy testing and improved ultrasonography, the death rate for minority women is almost twice that of white women, and minority adolescents are almost five times as likely to die of ectopic pregnancy. In this article, causative factors are identified, and the potential for race, gender, and age bias in diagnosis and treatment is discussed. Involvement by nurses in preventive programs, clinical research, and advocacy for policy change may help reduce ectopic pregnancy mortality rates.

Decrease in the rate of ruptured ectopic pregnancies: a successful team approach

Noting the increasing frequency of ectopic pregnancy and desiring to reduce both morbidity and mortality, OB/GYN physicians at a large midwestern HMO systematically monitored all ectopic pregnancies in their clinical practice as the first step in a quality improvement project. Data were collected on several components of care including access, risk assessment, diagnosis of ectopic pregnancy, and intervention. To ensure the system was able to coordinate new diagnostic and therapeutic modalities, several key initiatives were instituted to improve patient outcomes. These included application of comprehensive guidelines, increased ultrasound availability, and increased staff and patient awareness. Following the implementation of the initiatives, there was a decrease in rupture rates from 32% in 1988 to 5% in 1992. This paper discusses the development and integration of the initiatives into the staff model HMO.

Surveillance for ectopic pregnancy--United States, 1970-1989

PROBLEM/CONDITION

From 1970 through 1989, hospitalizations for ectopic pregnancy have increased in the United States; the number of cases has increased fivefold, from 17,800 to 88,400.

REPORTING PERIOD COVERED

1970-1989.

DESCRIPTION OF SYSTEM

Reported ectopic pregnancies were estimated from data collected by CDC's National Center for Health Statistics (NCHS) as part of the ongoing National Hospital Discharge Survey. Data from responding hospitals were weighted to represent national estimates. The number of deaths resulting from ectopic pregnancy was based on U.S. vital statistics collected by NCHS. Denominators for calculating ectopic pregnancy rates were the total number of reported pregnancies, which includes live births, legal induced abortions, and ectopic pregnancies. Data for live births were obtained from NCHS natality statistics and data for legal induced abortions from CDC's Division of Reproductive Health.

RESULTS

From 1970 through 1989, more than one million ectopic pregnancies were estimated to have occurred among women in the United States; the rate increased by almost fourfold, from 4.5 to 16.0 ectopic pregnancies per 1,000 reported pregnancies. Although ectopic pregnancies accounted for < 2% of all reported pregnancies during this period, complications of this condition were associated with approximately 13% of all pregnancy-related deaths. During this period, the risk of death associated with ectopic pregnancy decreased by 90%: the case-fatality rate declined from 35.5 deaths per 10,000 ectopic pregnancies in 1970 to 3.8 in 1989. The risks of ectopic pregnancy and death from its complications were consistently higher for blacks and other racial/ethnic minorities than for whites throughout the period.

INTERPRETATION

Although the general trend has been for the numbers and rates of ectopic pregnancy to increase over the 20-year period, the variability of the data does not permit meaningful conclusions to be made about year-to-year changes in the estimates of ectopic pregnancies, especially for the years 1988 and 1989.

ACTIONS TAKEN

These findings indicate the need to characterize behaviors and risk factors that may respond to preventive interventions. Until these risks factors are better characterized, early detection and appropriate management of ectopic pregnancies will remain the most effective means of reducing the morbidity and mortality associated with this condition.

Ectopic pregnancy--United States, 1988-1989

Although the number and rate of ectopic pregnancies in the United States increased from 1970 through 1987, they stabilized from 1987 through 1989 (1). This report presents data regarding the number and rate of ectopic pregnancies and ectopic pregnancy-related deaths in the United States from 1988 through 1989 and compares those data with information reported since 1970.

Ectopic pregnancy

The incidence of ectopic pregnancy has been increasing for many years and currently is two to three times higher than it was 20 or 25 years ago. The reasons for this are complex and include increased rates of pelvic and tubal infection, the use of the IUD, surgery in the pelvis for infertility, sterilization and other surgical procedures, in vitro fertilization, and improved diagnosis. Normal tubal physiology, the findings in affected tubes, and the mechanisms of how the ectopic pregnancy develops and involves the tube are considered. The cardinal points of the history and physical examination are presented in considerable detail. Further, the evolution of the tools of diagnosis--curettage, culdocentesis, laparotomy, laparoscopy, hormonal tests, and ultrasound-is considered. The different approaches to therapy are presented. Salpingectomy was once the method of accepted therapy, but currently conservative management (salpingostomy) is the most acceptable approach. More recently, selected patients are being treated with observation and a small subgroup are being managed with methotrexate and other chemical agents injected directly into the ectopic pregnancy. Ectopic pregnancy is still a leading cause of maternal death despite improved diagnosis and therapy. It should be remembered, however, that the total number of women who die from this condition is less than ever before and this is despite the rising incidence of ectopic pregnancy. There is still much to be learned about ectopic pregnancy, its etiology, diagnosis, and management.

Ectopic pregnancy surveillance, United States, 1970-1987

In 1987, both the rate of hospitalizations due to ectopic pregnancy and the number of women hospitalized increased from those reported in 1986. Although ectopic pregnancy represented 1.7% of all pregnancies in 1987, complications of this condition accounted for 12% of all maternal deaths in that year. The case-fatality rate was 3.4 deaths per 10,000 ectopic pregnancies, a decline of 30% from the rate of 4.9 deaths reported in 1986, and a 90% decline from the 35.5 deaths per 10,000 ectopic pregnancies reported in 1970. Although the racial gap decreased slightly in 1987, the risk of ectopic pregnancy remained 1.4 times higher for women of black and other minority races than for white women. The risk of death from this condition remained 1.8 times higher for women of black and other minority races.

Ectopic pregnancy concurrent with induced abortion: incidence and mortality

From 1972 through 1985, 24 women who underwent an induced abortion died as a result of a concurrent ectopic pregnancy. We analyzed data from the Joint Program for the Study of Abortion, National Hospital Discharge Survey, and the Centers for Disease Control Ectopic Pregnancy and Abortion Surveillance Systems to determine the incidence and mortality of ectopic pregnancy concurrent with induced abortion. During the period 1971 through 1985, the incidence of ectopic pregnancy concurrent with induced abortions was 1.35/1000 induced abortions, compared with 13.6/1000 pregnancies not terminated by induced or spontaneous abortion. The rate was higher among women who obtained abortions at earlier gestational age and among older women. The death-to-case rate for ectopic pregnancies concurrent with induced abortion was 1.3 times higher than that for women not undergoing abortion. Most of the deaths of women with ectopic pregnancy who underwent induced abortion were attributable to the failure to diagnose the ectopic pregnancy before the woman left the facility where the abortion was performed. Such deaths could be prevented by the provider of the abortion assuring that the tissue is examined for products of conception at the time of the abortion.

Ectopic pregnancy in the United States, 1970-1986

In 1986, both the rate of hospitalizations due to ectopic pregnancy and the number of hospitalizations decreased from those reported in the previous year, although the decreases were not statistically significant. If this leveling off of previous yearly increases becomes a continuing trend, possible explanatory hypotheses include a leveling off of disease occurrence, and an increasing use of outpatient management. The case-fatality rate rose slightly in 1986, to 4.9 deaths per 10,000 ectopic pregnancies, although this rate still represents an 86% decline from the 35.5 deaths per 10,000 ectopic pregnancies reported in 1970. In 1986, ectopic pregnancy accounted for only 1.4% of all pregnancies but was associated with over 13% of maternal deaths. Compared with white women, women of black and other minority races had a 1.6 times greater risk of ectopic pregnancy. Ectopic pregnancy remains one of the leading causes of maternal death in the United States and continues to be an important public health problem.

Maternal mortality in Hong Kong 1961-1985

The maternal mortality rate in Hong Kong fell from 0.45/1000 total births in 1961 to 0.05/1000 total births in 1985. During the period between 1961 and 1985 there were a total of 438 maternal deaths and 2,193,012 births. Of the 438 deaths 150 (34%) were due to haemorrhage during pregnancy and childbirth (ICD 640, 641, 666), 89 (20%) were due to pre-eclampsia (ICD 642, 643) and 60 (13.7%) were due to ectopic pregnancy (ICD 633). Comparison of maternal deaths by cause between the periods 1961-1965 and 1981-1985 showed an 86% reduction in deaths due to haemorrhage and pre-eclampsia and a 72% reduction in deaths due to ectopic pregnancy. Pulmonary embolism was not a major cause of maternal mortality.

Ectopic pregnancy surveillance, United States, 1970-1985

Ectopic pregnancy is now one of the leading causes of maternal death in the United States. In 1984 and 1985, both the numbers and rates of ectopic pregnancy increased. Since the rate of ectopic pregnancy remained unchanged for white women, the rate increase appears to be driven by the increasing rate among women of black and other races. Although ectopic pregnancies accounted for only 1.5% of the total pregnancies in 1984 and 1985, they accounted for 14% of the total maternal deaths in 1984 and for 11% of those deaths in 1985. However, the case-fatality rate for 1985 decreased to 4.2/10,000 ectopic pregnancies, down from the 35.5 deaths/10,000 ectopic pregnancies reported in 1970. Several factors may contribute to the increase in ectopic pregnancies, including heightened awareness of the condition, improved diagnostic technology, and possibly the higher prevalence of risk factors (e.g., acute and chronic salpingitis and sexually transmitted diseases) and the lower prevalence of protective factors (e.g., decreased use of oral contraceptives). Heightened awareness of the condition and improved technology may also be factors resulting in the decreased case-fatality rate.