Diagnosis and treatment of ectopic pregnancy
The most common site of localisation of an ectopic pregnancy is the fallopian tube. Rarely an ectopic pregnancy can be found in the ovary, a caesarean section scar, the abdomen or the cervix. Risk factors are previous ectopic pregnancy, PID, endometriosis, previous pelvic surgery, the presence of a coil and infertility. However, a third of women with an ectopic pregnancy have no known risk factors. NICE recommends a low threshold for offering a pregnancy test to women of childbearing age when they attend the surgery. Symptoms and signs appear when the tube starts to tear. When the tube ruptures, the woman will quickly become unwell and haemodynamically unstable because of rapid intra-abdominal blood loss. The most common symptoms of ectopic pregnancy are pelvic or abdominal pain, amenorrhoea, missed period or abnormal period and vaginal bleeding. A positive diagnosis of a urinary tract infection or gastroenteritis does not exclude an ectopic pregnancy. Signs of suspected ectopic pregnancy include pelvic, abdominal, adnexal or cervical motion tenderness, rebound tenderness and abdominal distension. Women who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding, should be referred directly to A&E, irrespective of the result of the pregnancy test. Stable patients with bleeding who have pain or a pregnancy of six weeks gestation or more or a pregnancy of uncertain gestation should be referred immediately to an early pregnancy assessment (EPA) service, or out-of-hours gynaecology service if the EPA service is not available. Diagnosis is confirmed by transvaginal ultrasound scan to identify the location of the pregnancy.
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ABSTRACT: PurposeIn a retrospective observational study, we evaluated the feasibility and safety of medical therapy with transabdominal ultrasound-guided injection of methotrexate (MTX) into the gestational sac (GS) in patients with interstitial ectopic pregnancies. Methods Fourteen interstitial ectopic pregnancies were treated with transabdominal ultrasound-guided injection of MTX (25 mg). All patients were hemodynamically stable. In all patients, the 10-cm distance between the GS and vaginal fornices was 10 cm, making transvaginal injection difficult. To evaluate feasibility and safety of the procedure, we assessed complications clinically and with imaging during a 1-year follow-up. ResultsIn all 14 patients, MTX injected locally into the GS successfully terminated the interstitial pregnancy, thereby avoiding surgery. There was no complications during follow-up. Conclusions The successful outcome in our patients suggests that the transabdominal route is feasible and safe as a nonsurgical option for terminating an ectopic interstitial pregnancy in patients in whom the transvaginal route is contraindicated or difficult, provided the patients are properly selected and operators have sufficient experience with the technique. (c) 2014 Wiley Periodicals, Inc. J Clin Ultrasound42:522-526, 2014
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ABSTRACT: Background Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment. Methods The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected. Results A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence. Conclusions EP/HP are tragic events in a couple’s reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.
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ABSTRACT: The aim of this study is to combine the ratios of venous serum/colporrhagia and hemoperitoneum/venous serum of human chorionic gonadotropin (hCG) and Progesterone (P) to generate and evaluate a new method to improve the prognosis of Ectopic pregnancy (EP). For patients with curettage procedure, curettage material and venous blood were obtained at the same time. For patients receiving culdocentesis and laparoscopic exploration, abdominal fluid and venous blood samples were obtained synchronously during surgery. The sensitivity and specificity of Rp/v-hCG>1.0 and Rp/v-P>1.0 for diagnosis of EP was 88.2% and 80.71%, 93.8% and 87.53%, respectively. The sensitivity of parallel test (Rp/v-hCG>1.0 or Rp/v-P>1.0) was 92.23%. The specificity of serial test (Rp/v-hCG>1.0 and Rp/v-P>1.0) was 100%. For the area under the ROC curve of Rp/v-hCG and Rp/v-P, the parallel test and serial test were 0.91 and 0.82,0.90 and 0.87, respectively. At the determining threshold point of 1.0, the sensitivity of Rv/c-hCG and Rv/c-P for the diagnosis of EP was 56.73% and 60.01%. The specificity was 100% and 100%, respectively. The sensitivity of parallel test (Rv/c-hCG>1.0 or Rv/c-P>1.0) was 73.33%. For the area under the ROC curve of Rv/c-hCG, Rv/c-P and the parallel test was 0.78,0.80 and 0.87, respectively. It is proposed that EP can more rapidly and accurately be diagnosed by multiple biomarkers' test of Rp/v-hCG>1.0 and/or Rp/v-P>1.0, as well as Rv/c-hCG>1.0 and/or Rv/c-P>1.0 via culdocentesis or curettage.
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