Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy

Thirty-four women with unruptured tubal ectopic pregnancy (EP) were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with tubal suturing (n = 19). The reproductive performance of these patients was compared with 24 patients who underwent salpingectomy for their EP (historical control). Using life table analysis, the cumulative probability of intrauterine pregnancy (IUP) at 12 and 24 months was 45% and 45% after salpingotomy without tubal suturing and 21% and 47% after salpingotomy with tubal suturing, respectively. The cumulative probability of IUP after salpingectomy (21% and 26% at 12 and 24 months, respectively) was significantly lower than after salpingotomy with or without tubal suturing. There was no difference in the cumulative probability of EP after salpingotomy with or without tubal suturing, but it was significantly higher than after salpingectomy. In 18 women who subsequently underwent laparoscopy or laparotomy, no significant difference was found between the degree of adhesions after salpingotomy with or without tubal suturing. These findings suggest that IUP after conservative treatment is higher than after salpingectomy, but recurrent EP is also higher. Intrauterine pregnancy occurs earlier after salpingotomy without tubal suturing than after salpingotomy with tubal suturing. This might be because of rapid return of tubal function after healing by secondary intention.     

Salpingotomy or salpingectomy in tubal ectopic pregnancy: What do women prefer?

There is an ongoing debate whether tubal ectopic pregnancy should be treated by salpingotomy or salpingectomy. It is unknown which treatment women prefer in view of the potentially better fertility outcome but disadvantages of salpingotomy. This study investigated women surgically treated for tubal ectopic pregnancy and subfertile women desiring pregnancy and their preferences for salpingotomy relative to salpingectomy by means of a web-based discrete choice experiment consisting of 16 choice sets. Scenarios representing salpingotomy differed in three attributes: intrauterine pregnancy (IUP) chance, risk of persistent trophoblast and risk of repeat ectopic pregnancy. An ‘opt out’ alternative, representing salpingectomy, was similar for every choice set. A multinomial logistic regression model was used to analyse relative importance of the attributes. This study showed that the negative effect of repeat ectopic pregnancy was 1.6 times stronger on the preference of women compared with the positive effect of the spontaneous IUP rate. For all women, the risk of persistent trophoblast was acceptable if compensated by a small rise in the spontaneous IUP rate. The conclusion was that women preferred avoiding a repeat ectopic pregnancy to a higher probability of a spontaneous IUP in the surgical treatment of tubal ectopic pregnancy.An ectopic pregnancy occurs when a fertilized egg gets stuck inside the Fallopian tube where it starts growing instead of passing on to the uterus. This may lead to serious problems, such as internal bleeding and pain. Therefore, in the majority of women, it is necessary to remove the ectopic pregnancy by means of an operation. Two types of surgery are being used in removing the ectopic pregnancy. A conservative approach, salpingotomy, preserves the tube but bears the risk of incomplete removal of the pregnancy tissue (persistent trophoblast), which then needs additional treatment, and of a repeat ectopic pregnancy in the same tube in the future. A radical approach, salpingectomy, bears no risk of persistent trophoblast and limits the risk of repeat tubal pregnancy, but leaves only one tube for reproductive capacity. It is unknown which type of operation is better, especially for future fertility. We investigated women’s preferences between these two treatments for ectopic pregnancy, i.e. does a better fertility prognosis outweigh the potential disadvantages of persistent trophoblast and an increased risk for ectopic pregnancy in the future? The study results show in the surgical treatment of tubal ectopic pregnancy that women preferred avoiding a repeat ectopic pregnancy to gaining a higher chance of a spontaneous intrauterine pregnancy. The risk of additional treatment in the case of persistent trophoblast after salpingotomy was acceptable if compensated by a small rise in intrauterine pregnancy rate.     

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary referral center.PatientsNinety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy.InterventionsSeventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy.Measurements and Main ResultsFactors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m² was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy.ConclusionsChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.     

Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX).DesignRetrospective cohort study.SettingSingle academic hospital system.PatientsPatients requiring surgery for ectopic pregnancy between 2006 and 2017.InterventionsA subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated.Measurements and Main ResultsAmong 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy.The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m² vs 29.3 ± 8.3 kg/m²; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates.MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure.Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08–6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09–0.54; p = .001) were.ConclusionThe initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.     

输卵管妊娠后再次妊娠的探讨

对输卵管妊娠后有生育要求的５８例行输卵管切除术，１５例行输卵管开窗术，３０例应用药物保守治疗。结果：１０３例治疗后６７例宫内妊娠，９例再次异位妊娠。     

Fertility after ectopic pregnancy

In the period July 1983 to March 1985, 264 women had surgery for ectopic pregnancy at Grady Memorial Hospital; 76 had postoperative hysterosalpingograms. Of these, 55 (76.4%) women were followed up for 3 to 41 months (mean, 23.8) to determine subsequent fertility. During the follow-up period, 30 pregnancies occurred among the 55 patients; 24 were intrauterine and 6 were repeat ectopic pregnancies. In the surgical group of 39 patients with salpingectomy, 60.8% of those desiring pregnancy achieved an intrauterine pregnancy. Of the 12 patients with salpingostomy, the three who desired pregnancy achieved it (100%). In the tubal abortion group, the two women desiring pregnancy conceived (100%). There were six repeat ectopic pregnancies (10.9%). Of the ectopic pregnancies, one occurred in the salpingectomy group (2.6%), four in the salpingostomy group (33.3%), and one in the tubal abortion group (25%). Five of the six ectopic gestations were found in the contralateral fallopian tube. Hysterosalpingographic evidence of contralateral tubal patency was a good prognostic indicator for subsequent intrauterine pregnancy. By contrast, one half of study patients with findings suggesting tubal occlusion still achieved an intrauterine pregnancy.     

Reproductive performance of women after two tubal ectopic pregnancies

Twenty-four women who had undergone total salpingectomy due to ectopic pregnancy and who subsequently underwent a laparotomy for a second ectopic pregnancy in their opposite tube were treated by the author. Treatment consisted of linear salpingostomy (n = 20) and partial salpingectomy (n = 4). The intrauterine pregnancy rate after linear salpingostomy in women who attempted to conceive was 50%, and the incidence of a third ectopic pregnancy was 27.8%. These findings suggest that linear salpingostomy should be considered in the management of a second tubal pregnancy in women with a single tube. The high incidence of a third ectopic pregnancy, however, is concerning.     

Three Recurrent Ectopic Pregnancies Case Report and Review of the Literature

EDITORIAL COMMENT: We accepted this case report for publication not solely because of its unusual anecdotal interest, or for its glimpse into reproductive requirements and wishes of women in Saudi Arabia, but for its summary of the literature on repeat ectopic pregnancy which should interest readers. Although preservation of the Fallopian tube by laparascopic salpingostomy is becoming the established treatment of unruptured ectopic pregnancy, we are unaware of a prospective trial comparing subsequent fertility in women with salpingostomy versus partial salpingectomy for unruptured ectopic pregnancy when the opposite Fallopian tube appears normal. In the present case there is no evidence that the preserved tube was useful from the reproductive point of view, although it remained patent. One reviewer of this paper performed a medline search and found that 'there are no prospective studies and only a few retrospective reports comparing fertility rates after salpingostomy and salpingectomy. Three major retrospective studies found no significant difference infertility or incidence of repeat ectopic pregnancy between the 2 procedures, but salpingostomy carries a 5–8% risk of persistent ectopic pregnancy, contributing to increased morbidity and cost. Fertility after ectopic pregnancy is affected much more by the status of the contralateral tube than by the procedure performed, with fertility rates exceeding 80% after salpingectomy when the opposite tube is normal'(A).
A. Rulin MC. Is salpingostomy the surgical treatment of choice for unruptured tubal pregnancy? Obstet Gynecoi 1995; 86: 1010–1013.
Summary: Further studies on the obstetric performance of women after recurrent ectopic pregnancies are needed to adequately counsel women who are still interested in future fertility, even after their third ectopic pregnancy.     

Laparoscopic treatment of tubal pregnancy

Seventeen tubal pregnancies were treated successfully with a laparoscopic procedure over the past four years. Four different laparoscopic techniques were used: salpingectomy, partial salpingectomy (midtube resection), fimbrial expression, and salpingotomy. "Preventive hemostasis" using vasopressin has made salpingotomy our treatment method of choice. Ruptured tubal pregnancy was not considered a contraindication to laparoscopic treatment. Four of the six women who were trying to conceive and were followed for longer than six months have had documented intrauterine pregnancies; one woman subsequently developed a contralateral tubal pregnancy which was treated by laparoscopic salpingotomy. Tubal ectopic pregnancy, even in the presence of rupture, can be managed effectively by a variety of laparoscopic techniques with benefits including minimal incision, short hospitalization, early return to full activity, and in many cases, a patent tube.     

Cervical pregnancy in assisted reproduction: an analysis of risk factors in 91,067 ongoing pregnancies

Research questionWhat is the frequency of cervical pregnancy in women undergoing assisted reproductive technologies (ART) and what are the risk factors?DesignCase-control study of women undergoing assisted reproductive technology (ART) at 25 private assisted reproduction clinics run by the same group in Spain. Two control groups (tubal ectopic pregnancies and intrauterine pregnancies) were established. The main outcome measure was frequency of cervical pregnancy. Demographic, clinical factors and IVF parameters were assessed for their influence on cervical pregnancy risk.ResultsThirty-two clinical pregnancies were achieved out of 91,067 ongoing pregnancies, yielding a rate of 3.5/10,000. Cervical pregnancies represented 2.02% of all ectopic pregnancies (32/1582). The main risk factors two or more previous pregnancies (OR 2.68; CI 1.18 to 6.07); two or more previous miscarriages (OR 4.21; CI1.7 to 10.43), one or more previous curettages (OR 3.99, CI 1.67 to 9.56), two or more previous curettages (OR 4.71; CI 1.19 to 18.66) and smoking (OR 2.82 CI 1.14 to 6.94). History of caesarean sections and tubal pregnancy was not associated with an elevated cervical pregnancy risk. Infertility conditions and endometrial thickness were similar across the three groups. The proportion of women from whom fewer than 10 oocytes were retrieved was higher in the clinical pregnancy group than in the IUP group.ConclusionsIn ART, the main risk factors for cervical ectopic pregnancy are a history of at least two pregnancies, miscarriages, at least one curettage and smoking. IVF parameters do not seem to influence the development of clinical pregnancies. Cervical pregnancies are less common in ART than previously reported, attributable to improvements in ART; a publication bias in early IVF reports cannot be ruled out.     

Aspirin for Endometrial Preparation in Patients Undergoing IVF: A Systematic Review and Meta-analysis

ObjectiveTo investigate the effect of aspirin on IVF success rates when used as an adjuvant treatment for endometrial preparation.Data SourcesRelevant publications were comprehensively selected from PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to November 15, 2020.Study SelectionRandomized controlled trials (RCTs) and retrospective cohort studies that used aspirin as an adjuvant treatment for endometrial preparation and reported subsequent pregnancy outcomes were included. Studies were excluded if aspirin was used before and/or during ovarian stimulation.Data Extraction and SynthesisThis systematic review and meta-analysis included a total of 7 studies. Risk of bias assessment was based on the methodology and categories listed in the Cochrane Handbook for the RCTs and the Newcastle-Ottawa scale for the retrospective studies. The primary outcome was live birth rate. Summary measures were reported as odds ratios (ORs) with 95% confidence intervals (CIs). There was significant evidence that aspirin for endometrial preparation improved live birth rates (OR 1.52; 95% CI 1.15–2.00). No effect was noted for clinical pregnancy rates (OR 1.37; 95% CI 1.00–1.87); however, aspirin was associated with improved pregnancy rates in a subgroup analysis of patients receiving oocyte donation (OR 2.53; 95% CI 1.30–4.92) and in the sensitivity analysis (OR 1.3; 95% CI 1.02–1.66). No effect of aspirin was found for implantation or miscarriage rates (OR 1.31; 95% CI 0.51–3.36 and OR 0.41; 95% CI 0.02–7.42, respectively).ConclusionThese findings support a beneficial effect of aspirin for endometrial preparation on IVF success rates, mainly live birth rates, outside the context of ovarian stimulation. However, this evidence is based on poor quality data and needs to be confirmed with high-quality RCTs.     

Pelviscopic treatment of tubal pregnancy

In 1978-1985 we operated on 111 tubal pregnancies pelviscopically. In 12 cases a salpingectomy was performed, in 99 patients the tubes both remained. 17 tubal abortions were extracted, in 82 cases the pregnancy was removed by salpingotomy. One second pelviscopy and one laparotomy were required because of postoperative bleeding. In one patient, a salpingectomy became necessary because of a post-operative infection. The pregnancy rate in 45 controlled infertility patients was 53%. A recurrence of ectopic pregnancy in the same or in the other tube occurred in 11%.     

Introduction and results in the endoscopic treatment of extrauterine pregnancy

After having applied endoscopic treatment of ectopic pregnancy for one year we herein report on 50 patients who were treated either by laparoscopy (in 20 cases) or laparotomy (in 30 cases). Conservative endoscopic surgery was performed in 12 cases (9 salpingotomy, 2 endoscopic restoration, 1 partial resection of the ovary) while conservative surgical methods by laparotomy were applied in 13 cases (8 milk out, 3 milk out with fimbrioplasty, 1 salpingotomy, 1 partial resection of the ovary). Partial endoscopic salpingectomy was necessary in 8 cases. Out of the women with laparotomy management 4 underwent an adnexectomy and 13 a salpingectomy. After laparoscopic treatment of ectopic pregnancy two patients developed an intrauterine pregnancy and in one case an ectopic pregnancy was observed again. In the laparotomy-group no intrauterine or ectopic pregnancy recurred in the period under review. There was no complication after laparoscopic management of ectopic pregnancy. However a temperature above 38 degrees C occurred in 5 cases after laparotomy caused by local inflammation or by post-operative infiltration. After endoscopic salpingostomy patency of the fallopian tubes was proofed by hysterosalpingography in 6 cases, and all tubes were found to be patent. Endoscopic management of ectopic pregnancy is recommended due to low post-operative morbidity rates and short time of hospitalization.     

Fertility outcomes subsequent to treatment of tubal ectopic pregnancy in younger Turkish women

Study Objective

The assessment of future fertility in patients that were hospitalized with diagnosis of tubal ectopic pregnancy.

Design

Between January 1998 and September 2008, we retrospectively reviewed 219 tubal ectopic pregnancy patients who were hospitalized. The patients using contraceptive methods, underwent previous pelvic or tubal surgery, pregnancy after in vitro fertilization, over the age of 28, and extratubal ectopic pregnancies were excluded. Patients who actively attempted to conceive were included. We called all the patients to see whether they had pregnancy in 24 months, and how long they had waited for this after the operation. Overall, we could not reach 14 patients who were treated surgically (n = 9) or medically (n = 5).

Setting

Department of Obstetrics and Gynecology, Ege University, Izmir, Turkey.

Participants

Women aged between 18 and 28 years that were treated because of tubal ectopic pregnancy and have concerns about infertility.

Interventions

Medical treatment with methotrexate (n = 34), salpingectomy (n = 62) salpingostomy (n = 37).

Main Outcome Measures

Intrauterine pregnancy rates, ectopic pregnancy rates and mean time to pregnancy after interventions.

Results

After questionnaire: in the methotrexate group; six of 29 (20%) had no pregnancy; 23 (79%) of them conceived, but three (10%) of the pregnancies were extrauterine. Thirty-seven patients received salpingostomy and 62 patients composed the salpingectomy group. Intrauterine pregnancy rates up to 24 months were established as 65.2% in salpingectomy (n = 55) and 60.1% in the salpingostomy (n = 35) groups respectively. No significant difference was noticed when pregnancy rates were compared among three groups (P = 0.942). Mean time to pregnancy in methotrexate group was 7.8 ± 2.2 months, and in salpingostomy and salpingectomy groups was 8.7 ± 2.2 and 9.3 ± 3.1 months respectively (P = 0.841).

Conclusion

Since we found no difference in terms of pregnancy rates among three groups, medical treatment appears to be more favored with early and accurate diagnosis. After salpingectomy, patients may conceive later in life when compared with other groups so selected patients should be assessed according to their age for the decision of assisted reproductive techniques.     

Role of laparoscopic salpingostomy in the treatment of hydrosalpinx

OBJECTIVE: To determine pregnancy rates after laparoscopic salpingostomy in occlusive distal tubal disease. To evaluate the relative impact of various historical, physical, and operative factors on pregnancy outcome using a multivariate statistical analysis. DESIGN: Prospective cohort. SETTING: University-affiliated tertiary care infertility clinic. PATIENT(S): One hundred thirty-nine infertile women with occlusive distal tube disease. INTERVENTION(S): Laparoscopic salpingostomy. MAIN OUTCOME MEASURE(S): The occurrence of intrauterine (IUP) and ectopic pregnancy (EP). RESULT(S): The overall IUP and EP rates were 24.5% and 16.5%, respectively. Analysis of historical variables, assessed independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions. CONCLUSION(S): Operative laparoscopy may be effective for the correction of hydrosalpinges in selected patients. The probability of achieving an intrauterine or an ectopic pregnancy can be predicted based on combinations of significant variables.     

Persistent peritoneal trophoblastic implantation following salpingotomy,salpingectomy, and methotrexate for ectopic pregnancy

A well recognized complication of conservative surgical treatment for tubal ectopic pregnancy, salpingotomy, is incomplete removal of trophoblastic tissue. Secondary trophoblastic implantation needs to be considered especially in cases of persistent disease following salpingectomy. We report an unusual and rare case of persistent peritoneal trophoblastic implantation following salpingotomy, salpingectomy and methotrexate for tubal ectopic pregnancy. This case illustrates that the treatment of ectopic pregnancy can prove to be difficult, even if the initial diagnosis is obvious. It shows that persistent trophoblastic disease can occur not only after salpingotomy but also after salpingectomy and methotrexate, hence the need for postoperative serum beta human chorionic gonadotrophin (Bhcg) in all cases. It also demonstrates that secondary implantation is a possibility in persistent disease and thorough examination of the pelvis, the peritoneal and serosal surfaces is mandatory.     

Risk factors associated with the rupture of tubal ectopic pregnancy

OBJECTIVE: To identify risk factors that may lead to the rupture of ectopic pregnancies. STUDY DESIGN: A retrospective chart review was performed on patients with ectopic pregnancies at the University of Miami/Jackson Memorial Hospital between 1/1/1995 and 3/1/2002. 738 patients were identified with ectopic pregnancies. Women with tubal rupture were compared to those without rupture. Variables analyzed were demographic data, patient-related risk factors (history of pelvic surgery, bilateral tubal ligation, history of pelvic inflammatory disease, previous ectopic pregnancy, intrauterine device use) and beta-human chorionic gonadotropin (betahCG) measurement. RESULTS: There were 439 (59%) cases with a ruptured and 299 (41%) cases with an unruptured ectopic pregnancy. Multivariate logistic regression analysis revealed that previous ectopic pregnancy (OR 2.88; 95% CI 1.92, 4.33) and betahCG level >or=5,000 mIU/ml (OR 1.85; 95% CI 1.12, 3.06) were the only significant risk factors for tubal rupture. CONCLUSION: Patients with betahCG levels >or=5,000 mIU/ml and patients with a history of a previous ectopic pregnancy are significantly more likely to experience a tubal rupture.     

Population-Based Study on the Effect of Socioeconomic Factors and Race on Management and Outcomes of 35,535 Inpatient Ectopic Pregnancies

Study ObjectiveTo evaluate whether socioeconomic variables influence the management and outcomes of ectopic pregnancies.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingHospitals in the United States participating in the Health Care Cost and Utilization Project.PatientsWomen (n = 35 535) with a primary discharge diagnosis of ectopic pregnancy.InterventionsEffect of socioeconomic factors and race/ethnicity on management and adverse outcomes of ectopic pregnancy.Measurements and Main ResultsDuring the 9-year study, 35 535 ectopic pregnancies were identified. The development of hemoperitoneum in 8706 patients (24.50%) was the most common complication. Asian race was the sociodemographic variable most predictive of hemoperitoneum (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.24–1.61; p < .01) and transfusion (OR, 1.62; 95% CI, 1.39–1.89; p < .01), and Medicare status was most influential on prolonged hospitalization (OR, 1.83; 95% CI, 1.36–2.47; p < .01). Major complications were not affected by socioeconomic factors. Laparotomy in 25 075 patients (70.6%) was the most common treatment option. Patients of Asian or Pacific Islander descent were least likely to be treated non-surgically (OR, 0.62; 95% CI, 0.51–0.76; p < .01), whereas Medicare recipients were most likely to be treated non-surgically (OR, 1.70; 95% CI, 1.32–2.18; p < .01). All non-white groups were less likely to undergo a laparoscopic approach.ConclusionMajor complications from ectopic pregnancy are not influenced by socioeconomic variables; however, less serious complications and management approaches are persistently affected.     

Culdocentesis Followed by Saline Solution–Enhanced Ultrasonography: Technique for Evaluation of Suspected Ectopic Pregnancy

Study ObjectiveTo evaluate the use of a technique consisting of culdocentesis followed by saline solution–enhanced pelvic ultrasonography in cases suspect for ectopic pregnancy in which an accurate diagnosis could not be made using routine transvaginal ultrasound.DesignRetrospective clinical study (Canadian Task Force classification III).SettingAcademic medical center.PatientsTwenty patients with an initial diagnosis of pregnancy of unknown location.InterventionsIn 20 patients with symptoms of early pregnancy and serum quantitative human chorionic gonadotropin concentration, ectopic pregnancy could not be confirmed or ruled out. Transvaginal ultrasound-guided culdocentesis was performed, and 300 to 400 mL of normal saline solution was injected into the posterior cul-de-sac and pelvis. Transvaginal ultrasound was repeated with particular attention to the floating fallopian tubesMeasurements and Main ResultsUsing this technique, a tubal pregnancy was visualized in 15 of 20 patients, and ectopic pregnancy was ruled out in 5 patients. In all patients, appropriate management was provided according to the final diagnosis, and consisted of either methotrexate, laparoscopic salpingostomy or salpingectomy, or expectant management in patients with abnormal intrauterine pregnancies.ConclusionUltrasound-guided culdocentesis followed by saline solution–enhanced pelvic ultrasound can be considered as a diagnostic tool in patients with suspected ectopic pregnancy in whom other methods fail to demonstrate this diagnosis.     

Trends for inpatient treatment of tubal pregnancy in Maryland

OBJECTIVE: The purpose of this study was to determine the burden of tubal pregnancy in Maryland in hospitalized patients and to elicit treatment trends. STUDY DESIGN: Patients who were admitted with tubal pregnancy from January 1, 1994, through March 31, 1999, were identified with the use of the Maryland Health Service Cost Review Commission discharge database. Combining this with census data, we calculated the incidence. Cases were then stratified by demographics, presentation, and surgeon volume. Outcome measures included type of medical treatment,conservative (salpingostomy or salpingotomy) or extirpative operation (salpingectomy, salpingo-oophorectomy, oophorectomy, hysterectomy), length of stay, charges, and disposition. The treatment groups were compared with the use of t tests and linear regression, and associations between demographics and type of operation were analyzed with logistic regression. RESULTS: The database included 3729 cases, which yielded an annual incidence of 5.2 per 10,000 women aged 15 to 45 years. Subjects averaged 29.6 years old and were predominantly African American(52.6%) and white (43.3%). Most of the women (67.8%) were seen in the emergency department and were treated surgically (90.7%). Conservative operation was performed in 18.1% of the women; extirpative operation was performed in 81.9% of the women. Significant predictors for extirpative operation were emergency department admission (odds ratio, 1.44; 95% CI, 1.18-1.75), increasing age (odds ratio, 1.07; 95% CI, 1.06-1.09), African American race (odds ratio, 1.87; 95% CI, 1.51-2.31), higher surgeon volume (odds ratio, 1.28; 95% CI, 1.04-1.57), and market area. Length of stay and total charges were higher for the extirpative group(P <.0001). The study lacked the power to detect differences in outcomes for other nonwhite races (5% power), laparoscopy versus laparotomy (15% power), or operating room charges (14% power). CONCLUSION: These data are limited to hospitalized patients and probably underestimate the true incidence of tubal pregnancy. Most patients underwent extirpative operation. Acuity of presentation and increasing age were appropriate predictors of this group. However, physician volume and black race were also predictors. This may be due to differences in the prevalence of disease, unmeasured clinical factors, patient and physician preferences for treatment, barriers that delayed care, or other socioeconomic factors.