宫外孕诊断及治疗中血清孕酮的价值分析

目的:研究宫外孕诊断及治疗中血清孕酮的价值。方法:选择2011年2月~2015年12月在我院进行诊治的宫外孕患者60例,随机分为观察组与对照组,每组各30例,并选取同期在我院进行孕检的正常妊娠者30例为健康组。对照组单纯检测血清人绒毛膜促性腺激素,并给予治疗;观察组联合检测血清人绒毛膜促性腺激素和孕酮并进行治疗。比较三组的血清孕酮和人绒毛膜促性腺激素水平,并比较观察组和对照组患者治疗后的血清人绒毛膜促性腺激素水平、内出血量和输卵管妊娠包块直径。结果:观察组和对照组宫外孕患者的血清孕酮和人绒毛膜促性腺激素水平均明显低于健康组(P0.05);观察组的血清人绒毛膜促性腺激素水平明显高于对照组(P0.05),内出血量和输卵管妊娠包块直径明显低于对照组(P0.05)。结论:血清孕酮检测在宫外孕诊断和治疗中的具有重要的临床应用价值,值得临床应用推广。     

Predictive value of a single serum pregnancy associated plasma protein-A or progesterone in the diagnosis of abnormal pregnancy

The value of a single measurement of serum levels of pregnancy associated plasma protein-A (PAPP-A) or progesterone (P4) in predicting abnormal gestations was assessed in 65 patients. P4 was greater than 20 ng/ml (mean +/- SEM 61.2 +/- 6.6 ng/ml, range 22.4-100.0 ng/ml) in all patients with normal intrauterine pregnancies (n = 21), and greater than 20 ng/ml (mean +/- SEM 8.5 +/- 3.9 ng/ml, range 0.1-68.8 ng/ml) in 16 out of 17 patients destined to abort spontaneously. Patients with ectopic gestations (n = 27) exhibited P4 values less than 20 ng/ml (mean +/- SEM 6.4 +/- 1.2 ng/ml, range 0.1-17.2 ng/ml). P4 levels in normal pregnancies were significantly higher (P = 0.001) than those of abnormal gestations. PAPP-A levels ranged from undetectable to 6448 mIU/ml in normal gestations. In 42 out of 44 abnormal pregnancies levels of PAPP-A were less than 100 mIU/ml, as were 7 out of 14 normal intrauterine pregnancies of less than 7 weeks gestational age. No ectopic demonstrated a value of PAPP-A greater than 50 mIU/ml and in 23 out of 27 ectopics, levels were undetectable. However, PAPP-A was less specific than P4 in correctly discriminating normal from abnormal gestations and exhibited lower positive and negative predictive values. It can be concluded therefore that a single PAPP-A measurement is of limited value in discerning normal from abnormal pregnancy prior to 8 weeks gestation. However, a single serum P4 is highly accurate and specific in detecting abnormal pregnancy, regardless of gestational age.     

Improved sensitivity and specificity of a single measurement of serum progesterone over serial quantitative beta-human chorionic gonadotrophin in screening for ectopic pregnancy.

The sensitivity and specificity of a single serum progesterone measurement was compared against two beta-human chorionic gonadotrophin (HCG) measurements 48 h apart in screening for abnormal pregnancy, i.e. ectopic pregnancy, completed or incomplete abortion. Of 1120 patients in the first trimester presenting with a positive urinary pregnancy test, 116/1120 (10.4%) had an ectopic pregnancy, 755/1120 (67.4%) had ultrasonographically confirmed intra-uterine pregnancies, and 249/1120 (22.2%) had abnormal intra-uterine pregnancies documented as complete, incomplete or missed abortions. Of the ectopic pregnancies, 113/116 (97.4%) had a serum progesterone level less than 25 ng/ml while 516/755 (68.3%) viable intra-uterine pregnancies had a serum progesterone level greater than or equal to ng/ml. Of the 1120 patients screened, 402 (35.9%) had both a serum progesterone and two HCG measurements and were eligible for inclusion in this study. Setting a cut-off of 25 ng/ml, the sensitivity and specificity of a single serum progesterone measurement was then compared against two serial HCG measurements, utilizing receiver operating characteristic curves. This analysis demonstrated that a single serum progesterone measurement was significantly more sensitive (P less than 0.05) than two HCG measurements in screening for an abnormal pregnancy. In some patients, a single serum progesterone makes possible the diagnosis of ectopic pregnancy 2 days earlier than two HCG determinations because a second blood sample was not required. We conclude that a single serum progesterone measurement should be added to serial HCG determinations as a standard diagnostic screening test for ectopic pregnancy.     

Potential use of single measurement of serum progesterone in detecting early pregnancy failure

Early pregnancy failure is a common pregnancy complication. In clinical practice, the time delay to distinguish viable from nonviable pregnancy is often distressing to patients and doctors. A highly sensitive and specific biomarker that accurately discriminates between viable and nonviable pregnancy would be useful for early intervention. Progesterone has been shown as a biomarker of early pregnancy failure. However the usefulness is still questionable due to the different cutoff values used. A study was conducted to determine the role of progesterone as a marker of early pregnancy failure and to establish the cut-off value in discriminating between viable and nonviable pregnancy. The study was carried out in the Obstetric and Gynecology Patient Admission Centre (OBPAC), Universiti Kebangsaan Malaysia Medical Centre (UKMMC) for a period of twelve months. Ninety-five pregnant women of 13 weeks or less period of amenorrhoea (POA) were recruited. Fourteen normal pregnant women were controls. The patients with early pregnancy failure were classified according to types of abortion. Single measurement of serum progesterone was carried out during admission. The outcome of pregnancy was followed up until 22 weeks of POA to ascertain viability of the fetus. Median progesterone levels were significantly lower in women with nonviable pregnancies compared with viable pregnancy [10.7ng/ml (0.60-49.80) vs. 45.9ng/ml (15.40-127.20) respectively, p<0.001]. Progesterone levels were also significantly lower in threatened abortion patients with outcomes of nonviable pregnancy compared with pregnancies that progressed on to the viability period [23.3 +/- 12.0 vs. 89.7 +/- 33.2 respectively, p<0.001]. At cut-off value of 32.7ng/ ml, progesterone had 90% sensitivity with 75% negative predictive value and 92% specificity with 97% positive predictive value. The area under curve for progesterone was 0.95 (95% Confidence Interval, 0.903-0.990). In conclusion, these findings indicate that serum progesterone can be used as a marker for early pregnancy failure.     

Early diagnosis of ectopic pregnancy using receiver -- operator characteristic curves of serum progesterone concentrations

The objective was to assess the usefulness of serum progesteroneconcentrations in the differentiation of intrauterine (viableand non-viable) and extra-uterine pregnancies. Progesteroneconcentrations were prospectively measured at 4, 5 and 6 weeksgestation in 338 pregnancies which resulted in 242 viable births,81 abortions and 15 ectopic pregnancies. Progesterone thresholdanalysis was performed using receiver—operator characteristiccurves. The progesterone threshold value for ectopic pregnancyat 4 weeks was 5 ng/ml, at 5 weeks 10 ng/ml and at 6 weeks 20ng/ml. A significant difference was observed between all intra-uterineversus ectopic pregnancies (P = 0.0005), but not between viableversus non-viable intra-uterine pregnancies (P = 0.37). Thedifferences were most clearly defined at 4 weeks and decreasedwith increasing gestation. We conclude that serum progesteroneand gestational age taken together can differentiate intra-uterinefrom extra-uterine pregnancies with a very high sensitivityand specificity at 4 weeks gestation, a time when ectopic pregnanciesare not evident on ultrasound examination.     

The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery

BACKGROUND: To evaluate the accuracy of transvaginal ultrasonography (TVS) for the detection of ectopic pregnancies (EPs) in women undergoing surgery for presumed ectopic pregnancy. METHODS: A prospective, observational study. Women were diagnosed with an EP using TVS if any of the following were noted in the adnexal region: (i) an inhomogeneous mass or blob sign adjacent to the ovary and moving separately from the ovary; or (ii) a mass with a hyper-echoic ring around the gestational sac or bagel sign; or (iii) a gestational sac with a fetal pole with or without cardiac activity. The final diagnosis was based on the findings at surgery and subsequent histology of removed tissues. RESULTS: 6621 consecutive women underwent TVS during the study; 200/6621 (3.0%) women were diagnosed as having an EP using TVS. Forty-eight non-surgically managed women were excluded from the analysis. 85.5% of women presented with symptoms and 14.5% were asymptomatic. In 88 (57.9%) cases an inhomogeneous mass or blob sign was visualized and in 20 cases (13.2%) an embryo +/- cardiac activity. Thirty-one (20.4%) had a hyper-echoic ring in the adnexa. In 11 (7.2%) cases there was no evidence of either an intra-uterine (IUP) or EP on ultrasound. Two (1.3%) IUPs were subsequently diagnosed as heterotopic pregnancies. There was no association between the presenting complaints and TVS findings. 152 surgical procedures were performed. In 5.9% (9/152) of these cases no EPs were confirmed in fallopian tube or pelvis at laparoscopy. In 9.1% (13/143) of cases an EP was visualized at surgery when not seen on the index ultrasound scan. The sensitivity and specificity of TVS to detect EP were 90.9% and 99.9%, respectively, with positive and negative predictive values of 93.5% and 99.8%, respectively. CONCLUSIONS: 90.9% of ectopic pregnancies in this study population can be accurately diagnosed using TVS prior to surgery. The diagnosis of an ectopic pregnancy should be based on the positive visualization of an adnexal mass using TVS. This should in turn result in a decrease in the number of false positive laparoscopies.     

血清β-HCG联合P、CK 、VEGF在异位妊娠早期诊断中的应用价值

目的探讨血清β-HCG联合孕酮(progesterone,P)、肌酸激酶(creatine k inase,CK)、血管内皮生长因子(vascu lar endothelial growth factor,VEGF)对异位妊娠早期诊断的价值。方法选择临床可疑异位妊娠病人50例为实验组,正常宫内妊娠50例作为对照组。采用放射免疫法(R IA)测定血清β-HCG、P水平,用ELISA法测血VEGF水平、酶动力法测CK水平,在β-HCG的基础上分析P、CK、VEGF联合检测对异位妊娠早期诊断的价值。结果异位妊娠组血清β-HCG、P水平明显低于正常宫内妊娠组,差异有显著性(P<0.05),血清VEGF水平明显高于正常宫内妊娠组,差异有显著性(P<0.05),两组血清CK水平差异无显著性(P>0.05)。结论β-HCG联合P、VEGF作为异位妊娠早期诊断有临床价值,而CK不宜作为异位妊娠早期诊断的辅助指标。     

Reply: Ultrasound diagnosis of ectopic pregnancy

Sir, We are pleased that Professor Barnhart acknowledges that thealgorithms currently used to define viability in the pregnancyof unknown location (PUL) population are flawed. It seems to us that there are three major issues that need tobe considered in relation to this subject:

1. How do we definea change in serum human chorionic     

The value of a single combined measurement of VEGF, glycodelin, progesterone, PAPP-A, HPL and LIF for differentiating between ectopic and abnormal intrauterine pregnancy

BACKGROUND: To evaluate whether serum concentrations of the non-placental markers vascular endothelial growth factor (VEGF), glycodelin (GLY) and progesterone (P) and the novel placental markers pregnancy-associated plasmaprotein A (PAPP-A), human placental lactogen (HPL) and leukaemia inhibiting factor (LIF) differ in ectopic pregnancy (EP) when compared with abnormal intrauterine pregnancy (aIUP). METHODS: A prospective clinical study was conducted at the University Hospital of Larissa, Greece. The study included 50 patients admitted with failed pregnancy and suspected ectopic pregnancy that were treated with curettage or laparoscopy and classified as histologically confirmed EPs (n = 27) or histologically confirmed aIUPs (n = 21) (mean gestational age of 7.15 and 7.3 weeks, respectively). Two suspected EPs proved to be normal IUPs and were excluded. VEGF, GLY, P, beta-HCG, PAPP-A, HPL and LIF were measured by enxyme-linked immunosorbent assay (ELISA) methods in a single pre-operative blood sample. RESULTS: The median VEGF concentration was 227.2 pg/ml in the EP group versus 107.2 pg/ml in the aIUP group (P < 0.001), with a suggested threshold value of 174 pg/ml for their differential diagnosis. LIF, P, PAPP-A, HPL and GLY serum measurements did not differ significantly between EP and aIUP. CONCLUSION: VEGF serum levels might be a useful marker in differentiating between EPs and aIUPs.     

Ultrasound diagnosis of ectopic pregnancy

Sir, It is with great interest that I read the recent article byDr Condous evaluating the diagnosis of women at risk for ectopicpregnancy (Condous et al. 2006). The methods modelling the outcomesof patients using a number of protocols advocated to diagnosea pregnancy of unknown location are sound. However, I     

Pregnancy: Laparoscopy: a dispensable tool in the diagnosis of ectopic pregnancy?

Laparoscopy is regarded as the final decisive diagnostic testin suspected ectopic pregnancy. The new non-invasive diagnosticmethods of transvaginal sonography and serum human chorionicgonadotrophin (HCG) monitoring now challenge this pivotal roleof laparoscopy. In this prospective study the diagnostic valueof an algorithm, combining transvaginal sonography with an HCGcut-off level between 1000 and 1500 IU/I (IRP) was tested in208 consecutive women at risk for ectopic pregnancy. Three diagnosticcategories are designated by the algorithm: intra-uterine pregnancy(n = 73), ectopic pregnancy (n = 89), and trophoblast in regression(n = 46). The latter category represents patients in whom nopregnancy could be located by transvaginal sonography, withan initial HCG concentration < 1500 IU/I, declining duringfollow-up. The algorithm has a sensitivity of 0.97, a specificityof 0.95, a likelihood ratio for a positive test of 19.4, anda likelihood ratio for a negative test of 0.03. The describeddiagnostic strategy thus proved extremely reliable in the safemanagement of patients at risk for ectopic pregnancy, and renderslaparoscopy obsolete.     

Maternal serum alpha-fetoprotein levels in ectopic pregnancy

Maternal serum alpha-fetoprotein (AFP) was measured at the time of presentation in 44 women with histologically proven ectopic pregnancy. Serum AFP levels were within the reference range in 32 women. Eleven women (25%) had AFP levels above the 90th centile of the normal range, including five women with a live fetus seen ultrasonically preoperatively. The two women with a ovarian pregnancy and a cornual pregnancy had levels below the median value for gestational age.     

The accuracy of multivariate models predicting ovarian reserve and pregnancy after in vitro fertilization: a meta-analysis

BACKGROUND: To review the accuracy of multivariate models for the predictionof ovarian reserve and pregnancy in women undergoing IVF comparedwith the antral follicle count (AFC) as single test. METHODS: We performed a computerized MEDLINE and EMBASE search to identifyarticles published on multivariate models for ovarian reservetesting in patients undergoing IVF. In order to be selected,articles had to contain data on the outcome of IVF in termsof either pregnancy and/or poor response and on the predictionof these events based on a multivariate model. For the selectedstudies, sensitivity and specificity of the test in the predictionof poor ovarian response and non-pregnancy were calculated.Overall performance was assessed by estimating a summary receiveroperating characteristic (ROC) curve, which was compared withthe ROC curve for the AFC as the current best single test. RESULTS: We identified 11 studies reporting on the predictive capacityof multivariate models in ovarian reserve testing. All studiesreported on the prediction of poor ovarian response, whereasnone reported on the occurrence of pregnancy. The sensitivityfor prediction of poor ovarian response varied between 39% and97% and the specificity between 50% and 96%. Logistic regressionanalysis indicated that cohort studies provided a significantlybetter discriminative performance than case–control studies.As cohort studies are superior to case–control studies,further analysis was limited to the cohort studies. For thecohort studies, a summary ROC curve could be estimated, whichhad a shape similar to that previously made for the AFC. CONCLUSIONS: The accuracy of multivariate models for the prediction of ovarianresponse in women undergoing IVF is similar to the accuracyof AFC. No data are available on the capacity of these modelsto predict pregnancy, let alone live birth. On the basis ofthese findings, the use of more than one single test for theassessment of ovarian reserve cannot currently be supported.     

Assessing the diagnostic accuracy of immunodiagnostic techniques in the diagnosis of schistosomiasis japonica: a meta-analysis

Immunodiagnostic tests are commonly used in the diagnosis for schistosomiasis japonica in field situation. Their diagnostic effect, however, has never been evaluated in a systematic way. We set out to review the value of tests including enzyme-linked immunosorbent assay (ELISA) and indirect hemagglutination assay (IHA) in the diagnosis of schistosomiasis japonica. A comprehensive search was conducted in order to identify all possible studies achieving the inclusion criteria. We undertook a meta-analysis of diagnostic ability that compared ELISA with IHA for the diagnosis of schistosomiasis japonica. Original articles were searched in Pubmed, Science Citation Index Expanded, Cochrane Library, Proquest and China National Knowledge Infrastructure. Data extractions were conducted independently by two reviewers. Summary receiver operating characteristic curves were used to summarize overall test performance. Funnel plot was used to analyze publication bias. Finally, 16 studies met inclusion criteria. In all studies combined, the diagnostic odds ratio (DOR) for IHA was 8.689 (95%CI 7.671 to 9.842) and ELISA was 3.691 (95%CI 3.018 to 4.515). The DOR for IHA was better than that for ELISA. IHA demonstrated TPR* = 0.721 and ELISA showed TPR* = 0.633. IHA performance was superior to that of ELISA. Nevertheless, difference of the accuracy between the two methods for diagnosis of schistosomiasis japonica has no statistical significance as shown by the result of Z test. We found that both IHA and ELISA can be used to rule in or rule out the diagnosis.     

The value of leucocyte alkaline phosphatase determinations in the diagnosis of ectopic pregnancy

Leucocyte alkaline phosphatase activity has been determined in a normal group, a group of pregnant patients, and a group of patients with ectopic pregnancy.     

重复异位妊娠的诊治体会

重复异位妊娠是指首次异位妊娠经保守性治疗或手术切除后，再次发生异位妊娠，对妇女的身心造成极大的伤害。本文就我院1998年1月至2003年12月共收治38例重复异位妊娠的病例进行回顾性分析，将其特点和诊治体会报道如下。     

Cervical ectopic twin pregnancy: diagnosis and conservative treatment: case report

A case of cervical ectopic twin pregnancy with cardiac activity in both embryos is presented. It was diagnosed in the eighth week of gestation by ultrasonography, and treated conservatively with intra-amniotic administration of methotrexate under ultrasonographic guidance followed by curettage. This procedure allows subsequent gestations.     

The management of ectopic pregnancy

The current management of ectopic pregnancy in a main teaching hospital was reviewed in the lead up to the amalgamation of the services of three maternity hospitals. A retrospective analysis of 54 women treated surgically for suspected ectopic pregnancy from January 2005 to May 2006 was carried out. The diagnosis and management of ectopic pregnancy, including length of stay in hospital, was reviewed. Analysis revealed that 46% of women were treated laparoscopically, 28% underwent laparoscopy with subsequent conversion to laparotomy and 26% of women had a primary laparotomy, of which only half were clinically unstable. Inexperience in laparoscopic surgery was found to be the primary reason for conversion to laparotomy. As the majority of operations were performed by NCHDs, there is a need to increase the training received in laparoscopic surgery to reach an acceptable standard laparoscopic rate of greater than 90%. This would result in shorter lengths of stay in hospital, substantial financial savings and greater patient satisfaction.