Plasma hCG and ultrasound in suspected ectopic pregnancy

The value of plasma hCG determinations (based on the recognition of β-subunit of hCG) and ultrasound was examined in 48 cases of suspected ectopic pregnancy. In 11 patients with the final diagnosis of ectopic pregnancy (23%), the plasma hCG was clearly subnormal (0.37–3.96 IU/ml), with only one exception, where a normally developed fetus was operated from the fallopian tube (hCG 21.1 IU/ml in the 8th wk). The plasma hCG levels allowed differentiation of the non-pregnant cases from the normal intrauterine pregnancies and the ectopic cases, but not at all between the different forms of intrauterine early pregnancy failures and ectopic pregnancies. By ultrasound, however, it was possible to reliably diagnose intrauterine pregnancies from the 7th wk of amenorrhea onwards, and to classify them into the normal and pathological subgroups. The direct demonstration of ectopic pregnancy by ultrasound is problematic, but the exclusion of intrauterine pregnancy by this method, combined with the simultaneous plasma hCG determination by sensitive and rapid method, can be recommended for primary examinations in suspected ectopic pregnancy.     

The value of sonography in suspected ectopic pregnancy.

Of 356 women undergoing sonography to diagnose or rule out an ectopic gestation, data sufficient to assign a final diagnosis were available on 260 of them. Ectopic gestation was diagnosed in 25 cases in this group and intrauterine pregnancy in 99, while the remaining 136 patients were found not to be pregnant. During sonography, ectopic gestations were suspected or diagnosed in 27 instances: In 17 cases this was in agreement with the final diagnosis, but neither an intrauterine nor an extrauterine gestation existed in 10 cases, although neoplastic or inflammatory masses were present. Of the 25 patients with the final diagnosis "ectopic pregnancy," this was not detected with sonography in 8 instances. Intrauterine pregnancies were diagnosed by sonar in 94 of the 99 cases. Although reliable sonar identification of ectopic gestation is not always possible, sonography is helpful in diagnosing intrauterine pregnancy so that surgical intervention can be avoided.     

A 1-hour hCG radioimmunoassay detection kit for the management of suspected ectopic pregnancy

Summary. The value of a rapid hCG kit was assessed in 60 patients undergoing laparoscopy or laparotomy for suspected ectopic pregnancy, of whom 30 were subsequently proven to be pregnant. A high degree of specificity (93%) and sensitivity (97%) was found, with one false-negative and three false-positive results. If the kit had been used as a routine on admission three patients would not have been inadvertently discharged before the diagnosis of tubal pregnancy and 27 could have avoided a laparoscopy to exclude tubal pregnancy.     

A 1-hour hCG radioimmunoassay detection kit for the management of suspected ectopic pregnancy

The value of a rapid hCG kit was assessed in 60 patients undergoing laparoscopy or laparotomy for suspected ectopic pregnancy, of whom 30 were subsequently proven to be pregnant. A high degree of specificity (93%) and sensitivity (97%) was found, with one false-negative and three false-positive results. If the kit had been used as a routine on admission three patients would not have been inadvertently discharged before the diagnosis of tubal pregnancy and 27 could have avoided a laparoscopy to exclude tubal pregnancy.     

The use of hCG and other pregnancy proteins in the diagnosis of ectopic pregnancy

Early diagnosis of ectopic pregnancy has been greatly improved by three diagnostic advances: the development of rapid and highly sensitive pregnancy tests, advances in ultrasound examination, and laparoscopy. The estimation of hCG is clinically superior to the measurement of any other pregnancy protein or biochemical parameter. If an hCG test has a sensitivity of 25 IU/1, then 90-100% of ectopic pregnancies will give a positive result. But, the hCG test cannot distinguish between intrauterine and ectopic pregnancy, and here ultrasonic examination and laparoscopy are routine diagnostic measures to identify the site of trophoblastic activity. If highly sensitive hCG tests are used routinely, they may detect small amounts of hCG so early in ectopic pregnancy that the tubal swelling is missed, or hCG may be reminiscent from trophoblastic activity of a previous regressing intrauterine or ectopic pregnancy. The lesson we learn from such cases is that a patient with an elevated hCG level in whom an intrauterine pregnancy has been excluded should be carefully followed-up as long as hCG remains elevated because of the possibility of an early ectopic pregnancy.     

Doubling time and hCG score for the early diagnosis of ectopic pregnancy in asymptomatic women

In a group of 20 asymptomatic women at increased risk for ectopic pregnancy, serum analyses were conducted prospectively early in pregnancy (amenorrhea less than or equal to 45 days) at 2-4-day intervals, to examine the rate of increase in hCG values. The initial serum hCG level, which was determined at the time of the first transvaginal ultrasound examination, was below the discriminatory zone of 1000 IU/l (2nd International Standard). In 8 out of the 9 women who were ultimately diagnosed as having an ectopic pregnancy, the increase in hCG progressed only slowly, with a doubling time exceeding 2.2 days. This slow hCG increase occurred in 2 out of the 11 women who were ultimately diagnosed as having an intra-uterine pregnancy; both women subsequently had an early spontaneous abortion. When Lindblom's hCG score was applied retrospectively to distinguish between intra-uterine and ectopic pregnancies, the hCG increase in all the ectopic pregnancies was below 190 IU/l per day and in 10 of the 11 women with an intra-uterine pregnancy above 190 IU/l per day. A slower rate of increase was observed in only one woman with an intra-uterine pregnancy; she had a spontaneous abortion. The doubling time of hCG and the hCG score are useful diagnostic aids in cases where transvaginal ultrasound has not (yet) given a definite answer regarding the presence of an intra-uterine pregnancy.     

Early recourse to laparoscopy in the management of suspected ectopic pregnancy. Accuracy and morbidity

Ninety-nine patients with suspected ectopic pregnancy (EP) who were subjected to laparoscopy/laparotomy over an 18-month period at Greenwich District Hospital, London, were audited. A third (32/99) of the cases had an EP, and 67 potentially avoidable laparoscopies were performed. A potentially avoidable laparoscopy was followed by a laparotomy in 27% of cases (18/67), and at least 13 of those laparotomies were unnecessary. In addition, two false-positive diagnoses of EP were made at laparoscopy, resulting in the avoidable loss of part or all of a single remaining fallopian tube. With the use of sensitive pregnancy testing at least 62 laparoscopies, 13 laparotomies and 1 case of pulmonary embolus might have been avoided in these patients and up to 195 days' hospitalization saved.     

Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial.

STUDY OBJECTIVE: To compare prospectively operative laparoscopy to laparotomy in the management of hemodynamically stable patients with ectopic pregnancy (EP). DESIGN, PATIENTS, Intervention: Patients with suspected EP presenting to a university-based residency teaching program were prospectively allocated to laparoscopy (n = 26) or laparotomy (n = 37) on alternating months for operative management. RESULTS: Operative times between laparoscopy and laparotomy did not differ significantly. Laparoscopy-treated patients had a significant reduction in estimated intraoperative blood loss, postoperative hospital stay, narcotic requirement, time to normal activity, and total hospital cost. There was no statistical difference in intrauterine pregnancy rates or in EP rates. CONCLUSIONS: In a university-based residency program, operative laparoscopy is a safe alternative for the management of appropriately selected patients with suspected EP.     

Gynecological laparoscopy and treatment of ectopic pregnancy

The aim of the present study is to show the advantages of the gynecologic laparoscopy for the diagnosis and treatment of the intact tubal pregnancy. For the fulfillment of this aim was made a prospective study for 5 years' period of the patients with diagnosis "Ectopic pregnancy", treated in Gynecological clinic of UMBAL-Pleven. The objects of observation were 33 women with diagnosis: "Intact ectopic pregnancy". Methotrexate was used by plan for 6 patients, in 7 patients was made laparotomy, and in 20 patients--gynecological laparoscopy. From the performed 20 gynecological laparoscopy, 16 women were recovered laparoscopically, in 14 of which was made partial salpingectomy, and in 2--milking. In one of the last two patients was injected Methotrexate in the bed of the gestational bag. In 4 women was necessary laparotomy, because of impossibility of performing of laparoscopic surgery. The authors emphasized the advantages of the gynecological laparoscopy for precise diagnosis and contemporary treatment of the intact ectopic pregnancy.     

Role of previous ectopic pregnancy in altering the presentation of suspected ectopic pregnancy

OBJECTIVE: To evaluate the differences in the presentations of women with and without a prior history of an ectopic pregnancy and a suspicion of a current ectopic. STUDY DESIGN: Evaluation of a cohort of patients presenting to an emergency department to exclude an ectopic pregnancy. Over a 58-month study period (January 1992-October 1996), 1,510 consecutive, pregnant women presenting to an emergency department with pelvic pain and/or vaginal bleeding to exclude an ectopic pregnancy were evaluated. A comparison was made of the presenting signs and symptoms between patients with and without a previous history of an ectopic pregnancy. RESULTS: Of patients presenting to exclude an ectopic pregnancy, 105 had a history of an ectopic pregnancy, and 1,355 had no such history. Fifty patients were excluded because they were lost to follow-up or transferred their care to another hospital. Those with a history of an ectopic pregnancy were more likely to be diagnosed again with an ectopic pregnancy, were older and were more likely to have a history of pelvic inflammatory disease and abdominal surgery. Patients with a history of an ectopic pregnancy presented earlier with a lower hCG level. CONCLUSION: Women with a previous history of an ectopic present in a clinically different manner than do those without such a history.     

腹腔镜早期诊治可疑异位妊娠的临床意义

目的 评估可疑异位妊娠(ectopic pregrnancy，EP)患者腹腔镜(laparoscopy，LSC)早期诊断和急诊手术的临床价值。方法 回顾分析1998年8月至2003年8月收治的经LSC手术治疗的可疑EP患者186例，均在入院24h内接受急诊LSC手术。结果 185例手术经腹腔镜完成，l例中转开腹，均无并发症发生。术中诊断EP172例(均经病理证实)，术前诊断符合率92．5％；其余病例依次为卵巢囊肿9例(4．8％)，宫内妊娠黄体破裂5例(2．7％)。32例合并不孕患者中25例有盆腔粘连，17例有输卵管卵巢病变，均行相应处理。12例少见异位妊娠(包括4例输卵管间质部妊娠，4例卵巢妊娠，3例腹腔妊娠，l例子宫肌壁间妊娠)，15例休克型异位妊娠，经腹腔镜手术亦获满意治疗效果。结论 急诊LSC手术不仅可早期确诊可疑EP患者，为保守性治疗赢得时间，而且还可同时对不孕症患者进行诊治。急诊LSC手术治疗休克型及少见异位妊娠亦是可行且安全的。     

Clinical value of pregnancy-specific beta 1-glycoprotein (SP1) and beta-hCG determination in serum in suspected ectopic pregnancy

We compared the clinical value of pregnancy-specific beta 1-glycoprotein (SP1) determination in serum by means of a highly sensitive enzyme-linked immunosorbent assay (ELISA) versus that of beta human chorionic gonadotropin (beta-hCG) determination in suspected ectopic pregnancy. The study comprised 58 women admitted consecutively with suspected ectopic pregnancy but without signs warranting immediate surgical intervention. Both SP1 and beta-hCG were found in 11 patients with ectopic pregnancy and in 8 patients with early intra-uterine pregnancy, whereas beta-hCG was detected in 4 and SP1 in 7 of 8 women with a recent abortion. Of 31 women presenting a non-pregnant condition, 2 were positive for both SP1 and beta-hCG. The measurement of SP1 in serum thus appears to be an alternative to beta-hCG measurement when ectopic pregnancy is suspected.     

The use of laparoscopy in the diagnosis of ectopic pregnancy and its clinical aspects]

11,8% (354 patients) of 3000 laparoscopies were performed because of suspected ectopic pregnancy (E.P.). In 23,4% of the diagnostic laparoscopy the diagnosis was confirmed. The rate of E.P. without bleeding was 11,8%. Laparoscopy is considered to be the method of choice to diagnose as well as to exclude E.P.     

The role of laparoscopy in the diagnosis of ectopic pregnancy: A plea for conservative management

This report evaluates the role of laparoscopy in patients admitted with the diagnosis of “Rule Out Ectopic”. There were 186 patients admitted to the Brookdale Hospital Medical Center in the 6-year period 1974–1979 inclusive with a diagnosis of “Rule Out Ectopic” or “Possible Unruptured Ectopic”. These patients were all laparoscoped. There were 157 satisfactory and 27 unsatisfactory laparoscopies. There were 71 ectopic pregnancies: 42 ruptured, 25 unruptured. Thirty-six cysts were diagnosed. The value of early laparoscopy is clearly established. Particular emphasis is placed on the diagnosis of the unruptured ectopic so that appropriate conservative management of the tube can be instituted in order to preserve potential reproductive capacity.     

Peritoneal relative to venous serum biomarker concentrations for diagnosis of ectopic pregnancy

Purpose

To retrospectively analyze the relationships of peritoneal serum relative to venous serum (R _p/v) ratios for human chorionic gonadotropin, CA-125, and creatine kinase to the ectopic pregnancy (EP).

Methods

Intra-abdominal fluid and venous blood samples of 118 subjects with suspected EP were obtained for biomarker measurements. R _p/v-hCG >1 was considered indicative of EP, and final diagnosis was based on surgical finding of an ectopic chorionic villous or gynecological ultrasound finding of an intrauterine gestational sac.

Results

R _p/v-hCG and R _p/v-CA-125 were both significantly greater for abortive as compared to ruptured EP and for the absence as compared to presence of active bleeding. However, neither ratio differed significantly between ampullary and isthmic EP. R _p/v-hCG and R _p/v-CA-125 correlated negatively with hemoperitoneum volume. R _p/v-hCG exhibited only modest predictive value for rupture. However, with R _p/v-CA-125 as the diagnostic criterion for rupture, sensitivity and specificity were 66.7 and 100%, respectively; in patients initially diagnosed with EP, R _p/v-CA-125 values <22.43 effectively predicted rupture. R _p/v-CK did not exhibit significant diagnostic value.

Conclusions

R _p/v-hCG values >1 combined with positive culdocentesis test findings reliably indicate the presence of EP. In patients initially diagnosed with EP, R _p/v-CA-125 values <22.43 predict tubal rupture.     

Combined use of serial serum human chorionic gonadotropin testing, ultrasound and panoramic diagnostic microhysteroscopy in the early diagnosis of ectopic pregnancy

It is not always easy to make an early diagnosis of ectopic pregnancy in patients with suspected ectopic pregnancy who in any case appear to be clinically stable, and in whom the serial serum study of human chorionic gonadotropin (hCG) testing and ultrasound (US) showed an abnormal pregnancy without adding any useful information for obtaining a differential diagnosis between ectopic pregnancy and non-viable intrauterine pregnancy (IUP). Typical management of these patients comprises expectant observation or carrying out a diagnostic laparoscopy. The purpose of this study was to examine the value of microhysteroscopy as an adjunctive procedure in the above-mentioned patients; the results of this clinical test show that in these patients, the microhysteroscopy may represent a simple and valid alternative to expectant observation or immediate laparoscopy.     

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     

A contemporary approach to suspected ectopic pregnancy with use of quantitative and qualitative assays for the beta-subunit of human chorionic gonadotropin and sonography

Although assays for the beta-subunit of human chorionic gonadotropin (beta-hCG) and ultrasonography have become popular diagnostic aids in the approach to patients with a suspected ectopic pregnancy, their true utility has not been clearly defined; in fact, the beta-hCG assay is so sensitive that proper clinical interpretation is sometimes difficult. A recent study describing a "discriminatory zone" (beta-hCG level of 6000 to 6500 mIU/ml), which correlates beta-hCG levels with appearance of a gestational sac on ultrasound scans, has been reported to be of diagnostic benefit. A prospective study of 103 women with suspected ectopic pregnancy was undertaken utilizing an algorithm which included beta-hCG assays (quantitative as well as qualitative) and ultrasonography. Seventy-three patients were found not to be pregnant, and seven had a normal pregnancy, 14 patients ultimately had a spontaneous abortion, and seven ectopic pregnancies were identified. The following conclusions were drawn: (1) a qualitative beta-hCG assay with a sensitivity of 25 mIU/ml is an effective test in screening for ectopic pregnancies; (2) the concept of a "discriminatory zone" is valid but not of frequent clinical utility, since most patients suspected of having an ectopic gestation have beta-hCG levels below this zone; (3) serial monitoring of beta-hCG values is an important diagnostic aid; (4) culdocentesis is still an important contemporary diagnostic test for the patient suspected of ectopic pregnancy.