Primary application of three-dimensional ultrasonography to early diagnosis of ectopic pregnancy

Preliminary evaluation of three-dimensional (3D) imaging for early diagnosis of ectopic pregnancy. Twelve asymptomatic patients before six weeks of amenorrhea and with no feature of intrauterine nor of ectopic pregnancy at traditional bidimensional ultrasonography were considered. Laparoscopy showed ectopic pregnancy in 9 cases. 3D transvaginal ultrasonography preceeding laparoscopy showed small ectopic gestational sac in 4 cases. Moreover the fallopian tube on the side of ectopic pregnancy could be imaged in all cases. This was possible because the fallopian tube was surrounded by a fine hypoechogenic border, an apparently specific feature which had not been reported previously. These preliminary data suggest that 3D ultrasonography is an effective procedure for early diagnosis of ectopic pregnancy in asymptomatic patients before six weeks of amenorrhea.     

Conservative medical and surgical management of interstitial ectopic pregnancy.

OBJECTIVE: To review the definition and diagnosis of interstitial and heterotopic interstitial pregnancy and to evaluate the conservative management of these conditions. DESIGN: A MEDLINE computer search was used to identify relevant studies. The mean values for the duration of amenorrhea, serum beta-hCG level, size of the ectopic mass, and success rates of the various treatment modalities were calculated from the raw data in the original publications. RESULT(S): A review of 41 patients with interstitial pregnancy who were treated with methotrexate systemically, locally, or in combination revealed an overall success rate of 83%. The mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 15,127 mIU/mL, and 23 mm, respectively. Among 22 patients with interstitial pregnancy who were treated with conservative laparoscopic techniques, the overall success rate was 100%. In this group, the mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 7,572 mIU/mL, and 31 mm, respectively. There were nine cases of heterotopic interstitial pregnancy. Seven patients were managed with potassium chloride injected into the ectopic pregnancy, and two patients were treated by laparoscopy. Overall, 67% of the coexisting intrauterine pregnancies resulted in successful deliveries and the remainder ended in spontaneous abortions. CONCLUSION(S): Cornual resection or hysterectomy with a laparotomy should no longer be the first line of treatment for a hemodynamically stable patient with an interstitial pregnancy. In selected cases, methotrexate and laparoscopy can be used successfully in treating early interstitial pregnancy.     

A study of 45 cases of ectopic pregnancy

Forty-five (45) cases of ectopic pregnancy are reported, an incidence of 1:742 pregnancies. Approximately (40%) of these patients gave a positive history of infertility, pelvic infection or abdominal surgery. Eighty-five percent (85%) of the cases were among gravida 1-5; nullipara and grand-multipara constituted the low-risk group. In 88% of the cases, the pregnancy was tubal ectopic, with 58.5% in the right fallopian tube. History of amenorrhea and lower abdominal pain with tenderness were the presenting features in 95% of the cases, while vaginal bleeding was reported by 50%. Vaginal examination is singled out as of poor diagnostic value, and laparoscopy is found to be the best diagnostic procedure. The pertinent medical literature is reviewed.     

天花粉、甲氨蝶呤、米非司酮对异位妊娠保守治疗的研究

目的:探索异位妊娠保守治疗的最佳疗效方案。方法:对昆明市延安医院1253例异位妊娠,其中676例行保守治疗。按用药分为用天花粉(A组310例)、甲氨蝶呤(MTX,B组70例)、米非司酮(C组60例)、MTX加米非司酮(D组184例)、天花粉加MTX加米非司酮(E组52例),观察疗效。结果:异位妊娠的保守治疗中E组成功率为94.0%,D组成功率为85.87%,A组成功率为85.16%,B组成功率为81.42%,C组成功率为60.00%。结论:临床显示,异位妊娠疗效方案E组疗效最佳,D组和A组有较高的临床应用优势。其次是B组,疗效最差的是C组。     

血清β-hCG监测在单剂量氨甲喋呤治疗异位妊娠中的临床价值

目的:评价动态检测血β-hCG 在单剂量氨甲喋呤(MTX)治疗宫外孕的临床价值。方法:回顾性分析MTX单剂量肌肉注射治疗宫外孕104例。结果:治疗总成功率为79.8%。成功组:用药前血β-hCG　948.7±893.8　mIU/mL,与失败组(1784.5±1157.5　mIU/mL)相比差异显著(P<0.001),用药后血β-hCG在d　2 以及d　7 下降显著。结论:MTX治疗前血β-hCG不是影响治疗效果的唯一危险因素,血β-hCG联合超声检测附件包块、后穹隆积液、是适时手术干预的重要客观指标,是保证治疗效果的关键。     

Methotrexate treatment for tubal pregnancy. Criteria for medical approach

AIM: The purpose of this retrospective study is to underline the indications for the use of systemic methotrexate (MTX) in tubal pregnancies. METHODS: One hundred and four (n=104) consecutive women were treated in our Department for tubal pregnancy. The database analysis showed that after careful respect for inclusion criteria, the treatment chosen was the intravenous administration of MTX in 68 patients, whereas laparoscopy constituted the primary treatment in 36 patients. A single dose of MTX was intravenously administered, diluted in saline solution, with a dosage of 50 mg/m2 of body surface. Close serum beta-hCG monitoring was performed, and in the case of a short fall, a 2nd dose of methotrexate was submitted. RESULTS: The overall success rate of MTX treatment was 91%; the 2nd dose of MTX was used in 12% of patients, whereas in only 6 out of 68 patients included in the medical treatment group a surgical approach for suspected tubal rupture was necessary. CONCLUSION: Treatment with methotrexate is effective and safe in the presence of these criteria: patient hemodynamically stable, absence of tubal rupture sign and hemoperitoneum, an adnexal mass with a diameter < or = 5 cm, an amenorrhea < or = 6 weeks and HCG levels < or = 10,000 mIU/ml. Laparoscopy is indicated in diagnostic uncertainty, when MTX is not suggested, when adnexal mass is > 5 cm, or in patients in which beta-hCG levels was > 10,000 mIU/ml.     

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.     

Interstitial pregnancy treated by transcervical aspiration of the gestational sac combined with systemic and local administration of methotrexate

Interstitial pregnancy, which is a rare form of tubal ectopic pregnancy, can grow larger than those within the fallopian tube because the surrounding myometrium is more expandable than the tube; many cases are advanced and treated with surgical resection or a large amount of methotrexate (MTX). This report presents a case of an advanced interstitial pregnancy treated with systemic MTX and laparoscopic local MTX injection combined with transcervical aspiration of the gestational sac. A 27-year-old nulliparous female presented with an interstitial pregnancy. Serum human chorionic gonadotropin (hCG) level was 90000 IU/L. MTX was given systemically (50 mg/m(2) i.m.) and the gestational sac was aspirated transcervically under laparoscopic guidance followed by local injection of 25 mg MTX. The patient received a total of only 95 mg MTX. The gestational sac disappeared and serum hCG became undetectable. The patient became pregnant spontaneously six months later, and delivered a live 2482-g infant in good condition by planned cesarean section at 36 weeks and 3 days of gestation. No defect of the myometrium was seen during the surgery. This therapy may be effective for interstitial pregnancy and can be performed safely with laparoscopy.     

Trichosanthin, a Chinese medicine for the medical treatment of ectopic pregnancy with high levels of β-hCG

This was a retrospective study of the effectiveness of trichosanthin (TCS), an active component isolated from the Chinese herb root tuber of Trichosanthes kirilowii on 140 cases of ectopic pregnancy with higher levels of β-human chorionic gonadotropin (β-hCG) managed with a single dose of TCS treatment. Trichosanthin has been used for medical treatment of ectopic pregnancy in China since the 1980s. This study was performed in a major teaching hospitals in China. The mean pretreatment level of β-hCG in the TCS treatment group was 3387.57 IU/L. The success rate of TCS treatment was 85% (119 of 140) which was similar to methotrexate (MTX) treatment. In 86 women with a high level of β-hCG (over 2000 IU/L), the success rate was 80.08% when treated with TCS. Of this group, 26 women who had a high level of β-hCG (over 5000 IU/L) showed a success rate of 73%. The level of β-hCG on days 4, 7, and 10 in TCS group was significantly decreased. This study has shown that TCS may be an option for the medical treatment of unruptured ectopic pregnancy or an option for the treatment of ectopic pregnancy with higher levels of β-hCG than currently recommended for medical management with MTX.     

Seventy-five ectopic pregnancies. Medical and surgical management

BACKGROUND: The aim of this study was to evaluate the treatment options of ectopic pregnancy. METHODS: Retrospective analysis performed on 75 patients diagnosed and hospitalised with ectopic pregnancy from January 1996 to May 2001. The medical records of each patient were evaluated. RESULTS: Treatment options: immediate surgical treatment (44%), methotrexate (MTX) therapy (43%) and expectant management (13%). MTX therapy success rate was 78.1%. Laparotomy was performed in 52.5% of surgically treated women. Over time there was an increase in the use of laparoscopic surgery: 75% of women underwent laparoscopy in the period 2000-2001. The rate of laparotomy still remains higher than the rate previously reported in other studies; the reason is that in our hospital no equipment for laparoscopy is available for emergency condition. Expectant management was effective when there was no pain and serum hCG levels were constantly low or were decreasing. CONCLUSIONS: Technological advances allow diagnosis of ectopic pregnancy before severe clinical symptoms arise. Although early diagnosis may contribute to higher incidence, it has also contributed to a decline in morbidity, deaths, and treatment costs. Timely and early diagnosis has made this disorder amenable to medical therapy, with success rates similar to those of traditional surgical treatment. Surgery is preferred when there are tubal ruptures or a high potential for rupture, hypotension, anaemia or ectopic pregnancy which is larger than 3 cm in diameter.     

A sensitive urine pregnancy test as an aid in the diagnosis of ectopic pregnancy

A highly sensitive 2-hour tube test for the detection of human chorionic gonadotropin (hCG) in urine was compared with the more resource-demanding radioimmunoassay for hCG in serum as an aid in the diagnosis of ectopic pregnancy. In a first series of 107 patients with the possibility of ectopic pregnancy, the urine test was positive in 31 patients, including all 15 patients shown to have an ectopic pregnancy. In a second series of 113 consecutive patients with ectopic pregnancy, the highly sensitive test was performed in 94 patients. It was positive in 90 (96%). The median time of amenorrhea at diagnosis was 7 weeks, and only 15 patients suffered a rupture of the fallopian tube. A highly sensitive urinary test for hCG is recommended as a screening method for patients giving even the smallest indication of ectopic pregnancy.     

剖宫产后切口妊娠的临床诊治分析

目的:研究剖宫产后子宫切口妊娠的临床表现及治疗方法等特征,为临床医生早期诊断、早期处理本病提供依据。方法:对25例患者的病史、临床表现、诊断方法以及治疗方法进行回顾性分析。结果:25例患者中有23例经阴道超声检查或彩色多普勒超声检查确诊;本病初诊误诊19例,误诊率76%,25例患者中保守治疗22例,21例痊愈,占95.45%;2例治疗失败而行全子宫切除术。结论:有剖宫产史的妇女因停经就诊时,要常规行阴道超声检查,对阴道超声怀疑切口妊娠的病例,有必要行彩色多普勒超声检查;彩色多普勒超声检查可作为诊断切口妊娠的主要方法;甲氨蝶呤加清宫术可作为治疗切口妊娠的主要方法,可有效地避免子宫切除。     

Persistent ectopic pregnancy following laparoscopic linear salpingostomy.

As the surgical approach for ectopic pregnancies evolves from radical to conservative procedures, the potential hazard of persistent ectopic pregnancy has become increasingly pertinent. From September 1, 1986 to August 31, 1989, 11 women with persistent ectopic pregnancy after laparoscopic salpingostomy were diagnosed and treated at Yale-New Haven Hospital. Persistent ectopic pregnancy was suspected in nine cases because of symptoms and in two because of plateauing beta-hCG titers. Ten of 11 patients underwent repeat surgery. Eight had partial or complete salpingectomy of the involved ipsilateral tube, two had repeat salpingostomies, and one was treated with methotrexate. When the 11 women with persistent ectopic pregnancies were compared with 70 patients treated successfully by laparoscopic salpingostomy using multivariate stepwise logistic regression, smaller size of the ectopic (P less than .01) and fewer days of amenorrhea (P less than .05) predicted persistent ectopic pregnancy after laparoscopic salpingostomy. Based upon our experience, we believe that earlier-treated ectopic pregnancies (ie, fewer than 42 days of amenorrhea) and/or smaller ectopics (ie, 2.0 cm or less in diameter) require treatment with particular caution and close postoperative surveillance.     

持续性异位妊娠的影响因素分析

目的：回顾性分析异位妊娠保守性手术后持续性异位妊娠发生的原因。方法：随机选取我科2008年至2010年因异位妊娠行腹腔镜下输卵管开窗取胚术患者98例,并分成AB两组,A组患者74例术中给予稀释后甲氨喋呤管残腔内注射．B组患者24例未给于药物管腔注射,两组患者于术后第3天及第5天复查血清13一HCG,同时进行相应处理,根据妊娠部位及术中是否用药与发生持续性异位妊娠的概率进行比较。结果：A组74例患者无1例发生持续性异位妊娠,B组24例患者发生持续性异位妊娠3例,其中2例妊娠部位为输卵管伞端妊娠,结论：输卵管伞端妊娠组织开窗清除术与输卵管其他部位开窗取胚术比较发生持续性异位妊娠率高（P〈O．05）。术中输卵管中未给药（甲氨喋呤）比术中给药发生持续性异位妊娠率高（P〈0．05）。     

Ectopic pregnancy resulting from gamete intrafallopian transfer and in vitro fertilization. Role of ultrasonography in diagnosis and treatment.

Forty-five cases of ectopic pregnancy occurred after gamete intrafallopian transfer (32 cases) or in vitro fertilization (13 cases). Ultrasonography positively identified ectopic pregnancy in 33 cases (73.4%) and suggested the presence of one in 7 cases (15.6%). There were five false-negative results (11.1%). The incidence of rare types of ectopic pregnancy after assisted fertility procedures, such as ovarian, heterotopic, cervical and ectopic pregnancy, in patients who had undergone a previous salpingectomy was increased. Ultrasound scanning was used to monitor three cases of nonviable ectopic pregnancy; all three required no further treatment. In 14 cases of viable ectopic pregnancy the gestational sac was aspirated and injected with potassium chloride and methotrexate. In seven of those cases no further treatment was needed. Patients who conceive as a result of assisted fertility procedures should be scanned four to six weeks after the procedure or sooner if they are considered at high risk of developing an ectopic pregnancy or if the condition is symptomatic.     

Serum beta-human chorionic gonadotrophin levels in the early diagnosis of ectopic pregnancy.

Beta-HCG in serum was analysed in 64 cases of ectopic tubal pregnancy who wree different groups; ruptured ectopic pregnancy, ectopic pregnancy accompanied by amenorrhea or adnexal mass and ectopic pregnancy without palpable adnexal mass and amenorrhea. The mean HCG levels for the three groups were 8 790 IU/l, 2 580 IU/l and 690 IU/l, respectively, which related more to the symptoms than to the estimated length of pregnancy. Eleven per cent of the women had an IUD and five per cent were taking low dose gestagens. Screening of cases with acute lower abdominal pain or irregular vaginal bleeding with beta-HCG in serum will facilitate an early diagnosis of ectopic pregnancy and be of special value in patients with less typical symptoms.     

Serial serum human chorionic gonadotropin (hCG) levels in ectopic pregnancy and first trimester miscarriage

Serial serum hCG levels were measured in 50 patients with a tubal ectopic pregnancy and 50 patients with spontaneous miscarriage of an intrauterine pregnancy. Serum samples were obtained at intervals of 3–5 d and more frequently if clinically indicated. The final diagnosis was confirmed by laparoscopy and/or dilatation and curettage. Data were analyzed using a linear regression model. Initial hCG concentrations ranged from 91 to 3,050 mIU/mL. Eighty percent of ectopic pregnancies and 35% of miscarriages were associated with rising hCG concentrations and no significant differences were noted in daily increments of hCG in the two groups (210 ± 30 mIU/mL/day for ectopic pregnancies versus 311 ± 55 mIU/mL/d for miscarriages). Twenty percent of ectopic pregnancies and 65% of miscarriages had falling hCG concentrations and significant differences were noted in the daily decrements of hCG for EP and AB (270 ± 52 mIU/mL/day for ectopic pregnancies versus 578 ± 28 mIU/mL/d for miscarriages (P≤ 0.05). Received: October 1999 / Accepted: 13 December 1999     

Treating cornual pregnancy with a single methotrexate injection: a report of 3 cases

BACKGROUND: Cornual pregnancy is a rare type of ectopic pregnancy. Methotrexate (MTX) has been used successfully for the treatment of tubal pregnancies; however, its use for interstitial pregnancies is less common. CASES: Three cases of cornual pregnancy were successfully treated with a single MTX injection (50 mg/m2), without complications. CONCLUSION: A single MTX injection as medical treatment is an alternative to surgical treatment of cornual pregnancies.     

Predictors of treatment failure for ectopic pregnancy treated with single-dose methotrexate

OBJECTIVE: To determine variables that predict treatment failure after methotrexate (MTX) treatment of ectopic pregnancy. DESIGN: Retrospective cohort study. SETTING: Canadian teaching hospital. PATIENT(S): Sixty patients diagnosed with and treated for ectopic pregnancy. INTERVENTION(S): A single dose of methotrexate (50 mg/m(2)) by i.m. injection. MAIN OUTCOME MEASURE(S): Resolution of serum beta-hCG or clinical evidence of treatment failure. RESULT(S): Treatment failure was observed following methotrexate administration in 65% of cases when initial beta-hCG was >4000 IU/L, but in only 7. 5% of patients when serum beta-hCG was <4000 IU/L (OR = 52.06, 95% CI 4.88-555.56). Patients who presented with pelvic pain without tenderness had treatment failure 56% of the time versus only 17% in those without pain (OR = 9.20, 95% CI 1.02-82.60). Treatment failure also occurred in 53% of patients presenting with vaginal bleeding versus 16% without bleeding (OR = 6.18, 95% CI 0.73-51.93). CONCLUSION(S): Methotrexate should not be used to treat ectopic pregnancy when initial beta-hCG is >4000 IU/L. Caution should also be exercised in using methotrexate for ectopic pregnancy when the patient presents with bleeding or pain even without tenderness.     

The Arias-Stella phenomenon and its diagnostic value in ectopic pregnancy. Studies of 86 cases with review of literature]

The role of the pathologist in the diagnostic of an ectopic pregnancy is mostly limited. Nevertheless, out of 59 tubaric pregnancies, in which endometrial curettage previous surgery, in 64.4% an ectopic pregnancy was predicted, on 30,5% there was a typical "Stella Arias" reaction, mean while on 33,9% there was a decidual-like reaction. The authors also make a revision on morphology and pathogenesis of "Stella Arias" reaction.