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: A case-control study of aetiological risk factors

Summary Aetiological risk factors for ectopic pregnancies were evaluated in a prospective study of 86 consecutive patients with ectopic pregnancy and two age- and parity-matched control groups of women in normal early pregnancy; those with planned pregnancy (65 pairs) and those having legal abortion (51 pairs). Compared with women with planned pregnancy, the patients with ectopic pregnancy more often had an IUD in situ, they had less frequently used hormonal contraception, and they had had more legal abortions, curettages, previous ectopic pregnancies, gynaecological operations and salpingo-oophoritis. Compared with women having legal abortion, the patients with ectopic pregnancy had favoured IUD-usage, or they had been without any contraception, and they had an increased frequency of previous ectopic pregnancies. The frequency of fertility problems was also increased in patients with ectopic pregnancy. Our results show that gynaecological plevic operations, endometrial curettage and evacuation, gynaecological infections, and usage of IUD are important risk factors for ectopic pregnancy, and that infertility seems to be a sign of this risk. In addition, the clinical characteristics of the patients with ectopic pregnancy were similar to those of the patients having legal abortion.     

Glycodelin serum levels in women with ectopic pregnancy

OBJECTIVE: Aim of our study was to determine circulating levels of glycodelin for biochemical monitoring of women with vaginal bleeding and/or abdominal pain in early pregnancy. The objective was, using glycodelin as a biochemical parameter, to distinguish between incomplete abortion and ectopic pregnancy in early weeks of gestation. STUDY DESIGN: In 169 women with a first trimester pregnancy, a single serum measurement of maternal glycodelin was taken. Patients were divided into groups according to the clinical and/or ultrasonografic findings at the time of hospitalisation:ectopic pregnancy, incomplete abortion and control. RESULTS: Glycodelin serum levels were significantly lower in patients with ectopic pregnancy comparable with intact pregnancy and incomplete abortion. There was no difference in serum levels between intact pregnancy and incomplete abortion. CONCLUSION: Glycodelin might represent a biochemical parameter in the differential diagnosis between ectopic pregnancies and incomplete abortion. The number of patients was too small to give reference ranges for pregnancy weeks.     

Ectopic pregnancy and medical abortion

OBJECTIVE: Medical abortion regimens have become more widely used to terminate early pregnancies. Medical abortion providers are concerned to diagnose and exclude women with ectopic pregnancy before initiating treatment, as with any early pregnancy termination. Yet, there is little information about whether the various pretreatment screening methods used are adequate. We reviewed published literature to determine the overall success of screening for ectopic pregnancy before medical abortion treatment. DATA SOURCES: We searched MEDLINE for articles on medical abortion regimens published before July 2003. METHODS OF STUDY SELECTION: We selected English language articles of studies of medical abortion with sample sizes greater than 100, which reported on ectopic pregnancy diagnosed after medical abortion treatment. Fifty-seven of 85 prospective studies and randomized trials (69%) met these inclusion criteria. We also included data from 2 unpublished studies because they were large and well-controlled and because they included serious adverse events known to us, which we did not deem fair to exclude from our analysis. TABULATION, INTEGRATION, AND RESULTS: Each article was reviewed by one author. Data from selected studies were compiled, and the frequency of ectopic pregnancy diagnosed after medical abortion treatment was calculated. Ectopic pregnancy was diagnosed very infrequently following medical abortion procedures, occurring in only 10 of 44,789 (0.02%) women. CONCLUSION: The very low frequency of ectopic pregnancies diagnosed after medical abortion treatment demonstrates that the various pretreatment screening methods that providers use to exclude patients with ectopic pregnancies are successful. Further, there is no evidence to suggest that medical abortion treatment leads to unusual complications for women with ectopic pregnancies.     

Identification of chorion villi in abortion specimens

The incidence of ectopic pregnancy is rising. All patients with a diagnosis of spontaneous abortion should be observed until they have been proved not to have an ectopic pregnancy. To help in identifying patients with an ectopic pregnancy, sensitive human chorionic gonadotropin tests, ultrasound, and laparoscopy have been used, yet there has been a tendency to forget the simple method of looking for chorion villi. In material specimens of 272 patients with the initial diagnosis of spontaneous abortion, the gynecologist could identify villi in 50% and the pathologist could identify another 30%. Thus, only 20% had to be observed by other methods and one-third proved to have an ectopic pregnancy.     

Human chorionic gonadotropin in early normal and pathologic pregnancy. Discordant levels in peripheral maternal blood and blood from the uterine and abdominal cavities

Human chorionic gonadotropin was assayed in 25 cases after first-trimester induced abortion, in 45 cases of spontaneous abortion in the first trimester, and in 27 cases of ectopic pregnancy. Blood was obtained from an antecubital vein and from the uterine cavity. In the cases of ectopic pregnancy blood was also obtained from the abdominal cavity. In the group of induced abortion the human chorionic gonadotropin levels in peripheral maternal blood did not differ significantly from the levels in the uterine cavity. In the groups of spontaneous abortion and ectopic pregnancy the human chorionic gonadotropin levels were significantly higher in blood from the uterine cavity and the abdominal cavity, respectively. In four cases (three with spontaneous abortion and one with an ectopic pregnancy) human chorionic gonadotropin was not detectable in peripheral maternal blood, while it was found in blood from the uterine and abdominal cavities.     

Coexisting ectopic and intrauterine pregnancies: a case report

BACKGROUND: The simulated presence of intrauterine and extrauterine pregnancies is a rare condition. Diagnosis is difficult, accomplished on grounds of strong suspicion (as in assisted reproductive treatment cases), on the presence of predisposing factors (pathology of salpinx) or as a coincidental finding in the emergency room when a patient presents after an elective or spontaneous abortion. An intrauterine pregnancy may be discovered in a patient who presents with ectopic pregnancy. CASE: A 40-year-old multigravida was diagnosed with coexisting extrauterine and intrauterine pregnancies when she presented with a right ectopic pregnancy in the emergency room. The patient underwent partial right salpingectomy and an elective abortion. CONCLUSION: Patients who present with acute pelvic pain must be investigated for coexisting ectopic pregnancy even though they have a proven intrauterine pregnancy. Such an investigation is even more important if the patient is undergoing assisted reproductive treatment. In patients who have had spontaneous or elective abortion, especially in cases of a gestation <4 weeks, the differential diagnosis should include coexisting ectopic pregnancy. Failure to diagnose this condition can have serious consequences.     

Ectopic pregnancy. II. Evaluation of the clinical value of a diagnostic algorithm for ectopic pregnancy

In this work we assessed clinical value of diagnostic algorithm of ectopic pregnancy introduced in the first part of study. We calculated sensitivity, specificity, exactness and positive and negative predictive value. Studies embraced 374 women admitted to Polish Mother's Memorial Institute in Lodz with suspicion of ectopic pregnancy. In 143 patients we recognised ectopic pregnancy in remained 231 absence of pregnancy, intrauterine pregnancy or abortion. Diagnostic algorithm, with estimation hCG and progesterone concentration in serum and use transvaginal ultrasound, seems to be useful tool allowed diagnosed early ectopic pregnancy. We obtained 100% sensitivity and specificity of algorithm in diagnosis ectopic pregnancy.     

Spontaneous heterotopic pregnancy leading to intrauterine abortion and subsequent ruptured ectopic pregnancy with a betahCG of 125 mlu/ml: a case report

A case of heterotopic pregnancy after spontaneous conception with abortion of the intrauterine pregnancy and subsequent rupture of the ectopic pregnancy is presented. A 34-year-old woman at five weeks of gestation presented with a ruptured ectopic pregnancy after spontaneous abortion of an intrauterine pregnancy with mIU/ml beta3hCG as low as 125 mIU/ml. Close monitoring of betahCG and careful ultrasound examination together with patient consultation are extremely important in the management of heterotopic pregnancy, especially in cases of diagnostic uncertainness.     

Human chorionic gonadotropin in maternal plasma after induced abortion, spontaneous abortion, and removed ectopic pregnancy

Human chorionic gonadotropin (hCG) in maternal serum was analyzed by a hCG-beta-subunit, radioimmunoassay (hCG-beta-RIA) in 36 cases after induced first-trimester abortion, 35 cases of spontaneous abortion in the first trimester, and in 35 cases of ectopic pregnancy to determine the time between the apparent removal of all trophoblastic tissue by surgical intervention and the disappearance of hCG from the blood. In the cases with induced abortion, hCG was detectable from 16 to 60 days, with a median of 30 days after uterine evacuation, in those with spontaneous abortion from nine to 35 days with a median of 19 days, and in the cases of ectopic pregnancy from one to 31 days with a median of eight, five days after laparotomy d. In the cases with induced abortion, hCG was detectable from 16 to 60 days, with a median of 30 days after uterine evacuation, in those with spontaneous abortion from nine to 35 days with a median of 19 days, and in the cases of ectopic pregnancy from one to 31 days with a median of eight, five days after laparotomy d. In the cases with induced abortion, hCG was detectable from 16 to 60 days, with a median of 30 days after uterine evacuation, in those with spontaneous abortion from nine to 35 days with a median of 19 days, and in the cases of ectopic pregnancy from one to 31 days with a median of eight, five days after laparotomy and removal of the affected tube. There was a significant correlation between the initial hCG levels and the disappearance time in each series. The demonstrated disappearance times are longer than previously recognized, which should be appreciated when hCG is analyzed after termination of early pregnancy.     

Epidemiology of ectopic pregnancy

The epidemiology of ectopic pregnancy, both the numbers and rates of which have tripled in the U.S. from 1970 to 1983, is analyzed here. Ectopic pregnancy includes all implantations other than in the anatomically normal uterine cavity. Improved ascertainment and earlier diagnosis, due to ultrasound and beta-hCG assays, have probably raised reported numbers of cases. On the other hand, there has been a parallel climb in incidence of pelvic inflammatory disease, thought to be associated with ectopic pregnancy. Rates were higher among women over 35, black, or previously married, although similar in various regions of the country. Mortality from ectopic pregnancy has become the most common cause of maternal death, replacing mortality resulting from illegal abortion. Despite this, death from ectopic pregnancy fell 7-fold, to 0.5 per 1000 ectopic pregnancies, or 40-50 per year nationally in 1983. Ectopic pregnancy was 3 times as risky for blacks as whites, 10 times as dangerous as childbirth, and 50 times as deadly as legal abortion. Some factors acting in the fatalities included delay of treatment (53%) and misdiagnosis (almost half).     

Rhythmic variation in the rate of ectopic pregnancy throughout the year.

OBJECTIVE: This study was conducted to determine whether the incidence of ectopic pregnancy follows a seasonal rhythm of occurrence. STUDY DESIGN: A retrospective analysis was performed on 15,639 pregnancies reported in a single department in 5.5 years (January 1992-June 1997). For each pregnancy the time of conception was estimated from medical records. Frequencies of conceptions that terminated in birth, spontaneous abortion, legally induced abortion, and ectopic pregnancy were distributed across the 12-month period. RESULTS: Total pregnancy showed a seasonal rhythm of occurrence, with peak values in March. The rate of ectopic pregnancy showed a rhythm with 2 peaks, in June and December. Nadirs were coincident with the peak and nadir of total conceptions and also with the equinoxes. Spontaneous abortions tended to show a rhythm the inverse of that of ectopic pregnancy. CONCLUSIONS: These data show an influence of the seasons on the rate of ectopic pregnancy, which may have implications for both the understanding of ectopic pregnancy's causative mechanisms and its prevention.     

Extremes of body mass index do not affect first-trimester pregnancy outcome in patients with infertility

OBJECTIVE: The study was undertaken to ascertain whether body mass index (BMI) affects first-trimester pregnancy outcome in patients with infertility. STUDY DESIGN: Records of 494 patients with a singleton gestation after treatment for infertility at a single academic center were retrospectively reviewed. Patients were classified with regard to BMI and treatment protocol. Outcomes were defined as ongoing pregnancy, spontaneous abortion, or ectopic pregnancy. RESULTS: The average rate of spontaneous abortion was 21.5% and of ongoing pregnancy 75.1%. This did not differ significantly in any of the BMI groups. When patients were further subdivided according to diagnosis or fertility treatment, the spontaneous abortion rate remained the same. CONCLUSION: The likelihood of a spontaneous abortion, ongoing pregnancy, or ectopic pregnancy in singleton gestations in the first trimester, after treatment for infertility, was not affected by BMI.     

Prompt diagnosis of ectopic pregnancy with the human chorionic gonadotropin test using exuded extract from endometrial curettings

Using saline solution including exuded extract from uterine curettings, hCG tests were performed in 63 women in whom there was a suspicion of ectopic pregnancy, and their results correlated highly with the microscopic existence of chorionic villi and trophoblasts. Ectopic pregnancy can be mostly excluded when the test is positive, and either ectopic pregnancy or complete abortion is probable when it is negative.     

Declining serum concentrations of the beta-subunit of human chorionic gonadotropin and ruptured ectopic pregnancy

Declining values of the beta-subunit of human chorionic gonadotropin may be associated with ectopic pregnancy or missed abortion. Sonography may not always establish a definitive diagnosis. A case is presented where expectant management of declining levels resulted in rupture of an ectopic pregnancy. Declining values of the beta-subunit of human chorionic gonadotropin should not give the clinician a false sense of security in managing first-trimester pregnancy disorders.     

Evaluation of leukemia inhibitory factor as a marker of ectopic pregnancy

OBJECTIVE: Our purpose was to determine the utility of measuring serum leukemia inhibitory factor, a cytokine expressed in the process of pregnancy implantation, for the diagnosis of ectopic pregnancy. STUDY DESIGN: Serum samples from 40 patients with positive serum quantitative beta-human chorionic gonadotropin levels were used for leukemia inhibitory factor determination. The serum leukemia inhibitory factor concentration was determined by enzyme-linked immunosorbent assay in the following 4 groups: (1) normal intrauterine pregnancies, (2) threatened abortions, (3) spontaneous abortions, and (4) ectopic pregnancies. RESULTS: All patients had detectable concentrations of leukemia inhibitory factor in serum, ranging from 2.44 to 8.25 pg/mL. Mean leukemia inhibitory factor concentrations for ectopic pregnancy were significantly lower (P <.05) than those of both the spontaneous abortion and threatened abortion groups by 1-way analysis of variance. When a cutoff point of serum leukemia inhibitory factor <6.2 pg/mL is assigned as diagnostic of ectopic pregnancy, leukemia inhibitory factor in patients with ectopic pregnancies versus all other groups predicted ectopic pregnancy with a sensitivity of 73%, specificity of 72%, positive predictive value of 50%, and negative predictive value of 88%. CONCLUSION: Serum leukemia inhibitory factor concentration is lowest in patients with ectopic pregnancy. A cutoff point of 6.2 pg/mL maximizes the sensitivity and specificity of the test; however, it is not sufficiently discriminatory to be used clinically for the diagnosis of ectopic pregnancy.     

Nonoperative management of ectopic pregnancy. A preliminary report

The incidence of ectopic pregnancy is increasing throughout the Western world; at present it is uncertain how much of this increase is due to the disease and/or its antecedents and how much due to better means of diagnosis. That the treatment of the obvious or ruptured ectopic pregnancy should be surgical is beyond doubt. However, in view of the natural tendency of some ectopic pregnancies to terminate in tubal abortion or complete resorption, it is questionable whether surgery is always necessary in every early case or whether some patients can be monitored by means of rising or falling levels of beta subunits of human chorionic gonadotropin (HCG) until tubal abortion or resorption occurs. This may be the best means of preserving tubal function and fertility.     

Human chorionic gonadotropin profile for women with ectopic pregnancy

OBJECTIVE: To analyze serial human chorionic gonadotropin (hCG) levels in women presenting to the emergency department who were ultimately confirmed to have ectopic pregnancies. METHODS: Human chorionic gonadotropin levels were obtained over time until definitive diagnosis. To be included, women had to have at least 2 hCG measurements. Human chorionic gonadotropin curves were characterized and their slopes calculated. RESULTS: Two hundred women received diagnoses of ectopic pregnancy with the help of serial hCG values and were included in the study. No curve adequately characterized the pattern of hCG values so attention was focused on the initial 2 values. The median slope of log hCG among all subjects was 0.11 (25% increase in 2 days). However, 60% of subjects had an initial rise in hCG, and 40% had an initial fall. The rise in hCG for women with ectopic pregnancies (0.28; 75% increase in 2 days) was slower than the mean increase reported for a viable intrauterine pregnancy. The decline in hCG for women with ectopic pregnancies (-0.225; 27% decline in 2 days) was slower than the mean reported for completed spontaneous abortion. However, 20.8% of women presented with a rise in hCG values similar to the minimal rise for women with a viable gestation, and 8% of women presented with a fall in hCG values similar to women with a completed spontaneous abortion. CONCLUSION: There is no single way to characterize the pattern of hCG for ectopic pregnancy. The number of women with ectopic pregnancy who experience an increase in hCG values is approximately equal to the number of those who experience a decrease. The hCG profile in women with ectopic pregnancy can mimic that of an intrauterine pregnancy or a completed spontaneous abortion in approximately 29% of cases. LEVEL OF EVIDENCE: II-2.     

Impact of abortion on subsequent fecundity

The impact of abortion on subsequent fecundity has been extensively studied, especially since abortion was legalized in Eastern Europe during the 1950s and 1960s and in Western Europe and the USA during the 1960s and 1970s. A review of this literature reveals a number of consistent findings. First, women who choose to have their first pregnancy terminated are at no increased risk of failing to conceive at a later date. Exceptions include abortions complicated by infection leading to pelvic inflammatory disease (PID). However, this combination of factors occurs very infrequently. Second, women whose first pregnancy is terminated by vacuum aspiration are at no increased risk of subsequent ectopic pregnancy. Exceptions may be women whose abortion is complicated by pre-existing C. trachomatis and others who experience post-abortion infection leading to PID. Third, women whose first pregnancy is terminated by vacuum aspiration are at no increased risk of subsequent mid-trimester spontaneous abortion, preterm delivery or low birthweight, when compared with women who are pregnant for the first time. Fourth, women whose first pregnancy is terminated by D&C may have an increased risk of subsequent ectopic pregnancy, mid-trimester spontaneous abortion and low birthweight. Fifth, more research is needed before it is clear whether multiple induced abortions carry an increased risk of adverse pregnancy outcomes. Finally, too little is known about fecundity following mid-trimester abortion procedures to state definitively that they carry no increased risk of adverse outcomes. However, studies to date suggest that instillation procedures carry little, if any, excess risk. Risks related to dilation and evacuation, if any, may be related to the method and extent of cervical dilation.     

妊娠滋养细胞疾病误诊问题

妊娠滋养细胞疾病常与妊娠有关联,故需与流产、异位妊娠、双胎妊娠等相鉴别;而妊娠滋养细胞肿瘤因有病灶转移甚至破裂,可有脑血管意外、急腹症等表现,另外,还常需与人流或药流后、产后胎盘残留、宫角妊娠等相鉴别。