Preliminary results on the role of embryonic human chorionic gonadotrophin in corpus luteum rescue during early pregnancy and the relationship to abortion and ectopic pregnancy.

The precise mechanisms by which corpus luteum (CL) function is modulated during early pregnancy are not known. Evidence in failed pregnancies (ectopic, abortions), shows that factors other than human chorionic gonadotrophin (HCG) could be involved in its regulation. The objective of this study was to investigate the dynamics of beta-HCG, progesterone and oestradiol production in early pregnancy and its relation to embryonic quality and topographic localization. Plasma concentrations of progesterone, oestradiol and beta-HCG were studied between days +12 and +21 after an in-vitro fertilization (IVF) embryo transfer in 11 intrauterine pregnancies, 10 intrauterine abortions and seven tubal pregnancies. Tubal pregnancies and abortions were grouped according to doubling time (DT) of HCG. Results showed that oestradiol concentrations were apparently reduced in both ectopic pregnancies and abortions compared with normal pregnancies. The fall in oestradiol concentrations was seen in ectopic pregnancies with an abnormal DT for HCG and in all abortions. When the ectopic pregnancy had a normal DT, oestradiol and progesterone concentrations were normal. In abortions, the fall in oestradiol and progesterone concentrations was less influenced by the DT of HCG. These findings suggest that corpus luteum function depends on an adequate DT of HCG more than an absolute value, and with normal trophoblastic tissue the site of implantation does not affect CL function.     

Clinical effectiveness of urinary human chorionic gonadotropin related protein (hCGRP) quantification for diagnosis of ectopic pregnancy

We detected pregnancy related new molecule, human chorionic gonadotropin related protein (hCGRP) in the urine of a pregnant women by using a monoclonal antibody against the human chorionic gonadotropin (hCG). This study examined the effectiveness of urinary hCGRP quantification in diagnosing ectopic pregnancy. This study included 40 normal pregnant women and 25 patients with ectopic pregnancy. Patients' serum and urinary intact whole hCG (i-hCG) and hCGRP concentrations were measured using sandwich ELISA and the ratio of hCGRP to i-hCG was calculated. Statistical analysis was performed using statistical package for social sciences (SPSS) 10.0. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the cut-off value to discriminate ectopic pregnancies from normal intrauterine pregnancies. Urinary hCGRP and hCGRP/i-hCG ratio in ectopic pregnancy group (14 +/- 6.6 ng/mL, 4.6 +/- 1.9%, respectively) were significantly lower than those of normal pregnancy group (149 +/- 10.2 ng/mL, 29.7 +/- 1.9%, respectively; p<0.001). Based on ROC curve analysis, a cut-off point of urinary hCGRP/i-hCG ratio <16.2% discriminated between ectopic pregnancy and normal pregnancy with a sensitivity, specificity, positive predictive value and negative predictive value of 92.0%, 90.0%, 32.6%, and 99.5%, respectively. Urinary hCGRP/i-hCG ratio measurement may be effective in diagnosing ectopic pregnancy.     

Endovaginal sonography for the early diagnosis of intrauterine and ectopic pregnancies.

Endovaginal sonography, together with beta-HCG titre, was used to diagnose ectopic pregnancy in 58 patients. Transabdominal ultrasound failed to conclude this diagnosis. The data from endovaginal sonography revealed the presence of a gestational sac in all 15 patients with normal pregnancies at a beta-HCG level of 1042 mIU/ml. Of the 23 patients with pathological pregnancies only 61% had an intrauterine gestational sac. Only 15% of the 20 patients with ectopic pregnancies showed an increase in beta-HCG greater than 66% in 48 h, while in normal pregnancy, this increase was found in 71% of the patients. The endovaginal findings of the ectopic gestation revealed a complex adnexal mass in 55%, a cystic mass in 30% and fluid in the cul-de-sac in 20%. The diagnostic indices of adnexal and cul-de-sac sonographic findings in the ectopic group further improved specificity and positive predictive accuracy. The detection of ectopic versus intrauterine gestation showed a high sensitivity of 95%, a specificity of 100%, a positive predictability of 100% and a negative predictability of 97%. The data confirm the value and reliability of endovaginal and cul-de-sac sonography, combined with measurement of the beta-HCG level in the early diagnosis of ectopic pregnancy. This combined approach not only makes the differentiation between normal and extrauterine gestation more accurate but also helps to avoid unnecessary diagnostic laparoscopy and hospitalization.     

Human chorionic gonadotrophin concentrations in early pregnancy after in-vitro fertilization.

There is increased risk of early pregnancy loss after assisted reproduction. In this study the use of serum human chorionic gonadotrophin (HCG) concentrations on day 12 after in-vitro fertilization (IVF) and embryo transfer was evaluated to predict pregnancy outcome. A total of 417 IVF pregnancies were included. Early pregnancy loss was defined as biochemical pregnancies, ectopic pregnancies and first trimester abortions. Vital pregnancies were defined as delivered singletons, multiple pregnancies and second trimester abortions. On the post embryo transfer day 12, the mean HCG concentration of the vital pregnancy group was significantly higher than in early pregnancy loss outcomes (P < 0.00001). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the cut-off value of HCG giving maximal sensitivity and specificity in order to discriminate early pregnancy losses from vital pregnancies. A patient with a HCG value higher than the calculated cut-off value (55 IU/l) had a 90% chance of having a vital pregnancy after IVF and embryo transfer. It can be concluded that a discriminatory HCG value on day 12 after IVF and embryo transfer cycles may be useful in predicting pregnancy outcome and may guide clinicians in identifying those pregnancies at risk for adverse outcomes and instituting more intensive surveillance in this population.     

Raised concentration of plasma creatine kinase BB isoenzyme in myelodysplasia.

A 72 year old woman presented with a suspected myocardial infarction. An echocardiograph showed no acute changes but her plasma creatine kinase (CK) activity was increased at 343 U/l (< 175 normal range). The apparent creatine kinase-MB activity by a CK-M subunit immunoinhibition assay was 350 U/l. In view of the discrepancy between the total creatine kinase and CK-MB activity plasma creatine kinase electrophoresis studies were performed which showed not only a band of creatine kinase-MM but also a band of creatine kinase-BB, 53% of the total creatine kinase activity. No band of CK-MB was seen. It later transpired that the woman had myelodysplasia. It is suggested that premalignant and malignant haematological conditions should be considered in patients with an unexplained increase in plasma CK-BB.     

Analysis of the incidence and risk factors associated with ectopic pregnancy following in-vitro fertilization and embryo transfer

Ectopic pregnancy is a well known complication of in-vitro fertilization(IVF) and embryo transfer. From March 1983 to December 1993,3000 clinical pregnancies were achieved at Bourn Hall Clinic,including 135 ectopic pregnancies (4.5%). Of these ectopics20 were heterotopic, eight ovarian, six bilateral tubal andthe remainder were singleton tubal pregnancies. The main riskfactor identified in the series was a history of pelvic inflammatorydisease (P < 0.001). The data also showed that ectopic pregnancyis at present more prevalent among patients in whom tubal damageis the reason for treatment. There was slight statistical evidence(P = 0.05) that patients having ectopic pregnancies receiveda higher volume of culture medium than those having normal deliveries.There was also an apparent trend (P = 0.07, not significant)that high progesterone/oestradiol ratio on the day of embryotransfer was associated with ectopic pregnancy. There was nostatistical evidence of association between ectopic pregnancyand a history of ectopic pregnancy, abortion, still birth, terminationof pregnancy, neonatal death, tubal surgery, ovarian stimulationprotocol, plasma concentration of oestradiol, luteinizing hormoneand progesterone, number of oocytes retrieved, number or qualityof embryos transferred, administration of general anaesthesiafor embryo transfer, and the number of patent Fallopian tubes.Awareness of the risk factors associated with ectopic pregnancyplays an important part in the early diagnosis of this potentiallyfatal condition.     

Placental protein 14 in human in-vitro fertilization early pregnancies.

Placental protein 14 (PP14) and human chorionic gonadotrophin (HCG) were analysed in patients participating in an in-vitro fertilization-embryo transfer programme which did not include any kind of luteal support. Women with normal pregnancies, spontaneous abortions, ectopic pregnancies, biochemical pregnancies and non-pregnant women were compared. A combination of HCG and PP14 analyses distinguished between normal and abnormal implantation as early as 15 days after oocyte retrieval. The product of HCG (IU/l) and PP14 (micrograms/l) concentrations differed significantly between normal pregnancy, spontaneous abortion and ectopic pregnancy (P = 0.0248). It is concluded that both endometrial (PP14) and trophoblastic (HCG) markers, when used in combination, exhibit changes in abnormal implantation which may be clinically useful.     

Pregnancy: The prediction of ectopic pregnancy after in-vitro fertilization and embryo transfer

Data from 135 patients who suffered ectopic pregnancies andfrom 135 patients who progressed to singleton deliveries afterin-vitro fertilization and embryo transfer have been analysedretrospectively. The ectopic pregnancies represent all suchcases observed at Bourn Hall Clinic between 1983 and 1993. Thedelivered group was randomly selected from the same time period.The ectopic pregnancies included 20 heterotopic, eight ovarianand six bilateral tubal pregnancies; the remainder were singletontubal pregnancies. The aim of this study was to identify thevariables which differed systematically for the two groups ofpatients and to explore whether such variables could be usedto predict ectopic pregnancy at an early stage. The mean plasmaconcentration of human chorionic gonadotrophin and progesteronefor the ectopic pregnancy group was significantly lower thanthat for the singleton delivery group (P < 0.001). However,there was such a degree of overlap that it was impossible todevise a cut-off concentration for either hormone which wouldoffer a clinically useful predictor of ectopic pregnancy. Nevertheless,using the discriminant function analysis of these data, togetherwith the history of pelvic inflammatory disease, we could predictup to 90% of cases of ectopic pregnancy by day 23 after embryotransfer, long before ultrasound imaging would be useful.     

Leukemia inhibitory factor (LIF) is immunohistochemically localized in tubal ectopic pregnancy

Leukemia inhibitory factor (LIF) is essential for implantation of the embryo in the endometrium. It is not clear whether the blastocyst requires expression of LIF for implantation into tissues other than endometrium. Immunohistochemical localization of LIF was performed in the fallopian tube of 20 women with ectopic pregnancies, 7 women with normal pregnancies and 20 healthy non-pregnant women. Fallopian tubes were evaluated from specimens taken during tubal ligation in normal pregnancies and non-pregnant fertile women or at operation for tubal surgery in ectopic pregnancies. Biopsies were assayed by immunohistochemistry. Semi-quantitative immunohistochemical reaction scores (IRS) were used for immunohistochemical analyses. Immunolabeling of LIF was detected in the surface epithelium and stroma of fallopian tubes in all subjects. IRS score in the epithelium and stroma of non-pregnant women and women with intrauterine pregnancy were similar (p>0.05). However, women with ectopic pregnancy had significantly increased labeling of LIF compared to others (p<0.05). Immunohistochemical labeling of LIF in the fallopian tube was found to be increased in ectopic pregnancies compared to non-pregnant and healthy pregnant controls. This may indicate a role of LIF in the ectopic implantation of embryos.     

The value of serum levels of oestradiol, progesterone and beta-human chorionic gonadotrophin in the prediction of early pregnancy loss.

Serial serum levels of oestradiol, progesterone and the beta-subunit of human chorionic gonadotrophin (beta-HCG) had been performed in 674 cycles in women conceiving a singleton pregnancy, either spontaneously or as a result of assisted conception. To determine the value of these estimations in the prediction of early pregnancy loss, frequency distribution curves and receiver operating characteristic curves were derived for the respective hormones measured at weeks 4-7 of gestation and expressed as multiples of the median (MoM) values in pregnancies occurring both with and without ovarian stimulation. A cut-off level of beta-HCG less than 0.5 MoM gave a sensitivity of 68% with an odds ratio of 4.0 at 7 weeks in unstimulated cycles in the prediction of pregnancy failure. A cut-off of 0.8 MoM for progesterone gave a sensitivity of 59% and an odds ratio of 2.8. Prospective hormonal monitoring during the early weeks of gestation may be useful in the prediction of early pregnancy loss and should help to avoid the emergency presentation of some of the complications of early pregnancy, in particular ectopic pregnancy. The limitations imposed by multiple pregnancies and uncertain gestation due to menstrual data may restrict the use of this strategy to specialist fertility centres.     

Creatine kinase and lactate dehydrogenase levels as potential indicators of Trypanosoma cruzi infectivity and histotropism in experimental Chagas' disease

The results of the present study reveal an early increase in activity levels of creatine kinase and lactate dehydrogenase in the plasma of mice infected with Trypanosoma cruzi strains K-1, X-1, and Tulahuen as compared with uninfected control mice. An increase in creatine kinase activity was detected earlier in K-1- and X-1-infected mice than in Tulahuen-infected mice. Moreover, an increase in lactate dehydrogenase activity occurred at 1.5 days after infection with the X-1 and Tulahuen strains and at 3.5 days after infection with the K-1 strain. Generally, the highest activity levels were found in the plasma of mice infected with the most virulent and lethal Tulahuen strain as compared with the less virulent and nonlethal K-1 and X-1 strains. A significant decrease in creatine kinase levels occurred later in the tissues than in the plasma of K-1- and X-1-infected mice but did not vary significantly in any of the tissues from Tulahuen-infected mice. Similarly, the specific activity of lactate dehydrogenase in tissues from K-1- and X-1-infected mice dropped at a later stage than did the activity in plasma, but infection with the Tulahuen strain caused an earlier reduction in the activity of lactate dehydrogenase in the heart and skeletal muscle. The activity levels of both enzymes in plasma and tissues showed a linearly negative and statistically significant correlation. The present study reveals that levels of creatine kinase and lactate dehydrogenase activity in plasma could be early indicators of and suitable tools for monitoring of the infectivity of these strains of T. cruzi and might reflect their inherent histotropism during experimentally acute Chagas' disease. Received: 1 September 1999 / Accepted: 1 October 1999     

Leucocyte populations in ectopic tubal pregnancy.

Leucocytes at the ectopic implantation site in 10 cases of early tubal pregnancy were characterised with a series of monoclonal antibodies using an indirect immunoperoxidase technique on cryostat sections. Most were HLA-DR positive macrophages, and there were a small number of mature T lymphocytes (UCHT1 and Dako-T1 positive cells). These results were compared with those reported in normal first trimester intrauterine pregnancies, and the contributions of the various leucocyte types to successful implantation at both the ectopic and intrauterine sites were assessed.     

The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy

BACKGROUND: To determine the effectiveness of an initial transvaginal ultrasound scan (TVS) in the detection of ectopic pregnancy in consecutive women attending an early pregnancy unit (EPU). METHODS: This was a prospective observational study. Unselected women attending a dedicated EPU underwent a TVS. Women were classified as having an intrauterine pregnancy (IUP), ectopic pregnancy or pregnancy of unknown location (PUL). Women with a PUL were followed up until the final location of the pregnancy was determined. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% confidence intervals (CIs) for the initial TVS in the diagnosis of ectopic pregnancy were calculated. RESULTS: During a one-year study period, 5318 consecutive women attended the EPU. Outcome data were available for 5240 (98.5%) women. Of these, the initial TVS showed an IUP in 4693 (89.6%) cases and an ectopic pregnancy in 91 (1.7%) cases. The remaining 456 (8.7%) women were classified as PUL, and of these 31 (6.8%) were subsequently found to have ectopic pregnancies. The overall sensitivity of the initial TVS in the diagnosis of ectopic pregnancy was 73.9% (95% CI: 65.1-81.6) with a specificity of 99.9% (95% CI: 99.8-100), a PPV of 96.7% (95% CI: 90.7-99.3) and an NPV of 99.4% (95% CI: 99.2-99.6). CONCLUSIONS: In unselected women attending an EPU, pregnancy location can be diagnosed accurately in over 90% of all pregnancies and in 73.9% of ectopic pregnancies with a single TVS.     

Role of E-selectin for diagnosis of myocardial injury in children of age up to 14 years

Background: Effects of myocardial injury on E-selectin remain unclear. Thus, we investigated the diagnostic value of E-selectin for myocardial injury in children of no more than 14 years of age, which determined the scoring method of myocardial injury. Methods: In this prospective study, plasma E-selectin, cardiac troponin I (cTnI) and creatine kinase isoenzyme MB (CK-MB) concentrations in pediatric patients with myocardial injury (myocardial injury group, n=85) were measured. The control group comprised 80 patients without myocardial injury, and the case-control study method was selected at the same time. The definition of cardiac injury was based on cTnI and CK-MB (with or possibly without abnormal ECG evidence). Diagnostic value of E-selectin for myocardial injury was determined by analyzing receiver operating characteristic (ROC) curves. Results: The differences between the two groups were of statistical significance (P<0.001). For the 85 patients with myocardial injury, the area under the ROC curve (AUC) value for plasma E-selectin levels was 0.945 with a 95% CI of 0.899-0.991 and the optimal diagnostic cut-off value 29.67 ng/ml (positive likelihood ratio (positive LR=72.5); AUC value for plasma cTnI level was 0.848 with a 95% CI: 0.737-0.960 and the optimal diagnostic cut-off value was 0.155 µg/L (positive LR=12.3); AUC value for plasma CK-MB levels was 0.946 with a 95% CI: 0.903-0.989 and the optimal diagnostic cut-off value 24.26 IU/L (positive LR=72.5). Conclusions: E-selectin is more effective than cTnI in diagnosing myocardial injury as an important biological marker of myocardial injury- an important index of pediatric cardiac injury score.     

Pregnancy: Ectopic pregnancy after in-vitro fertilization is characterized by delayed implantation but a normal increase of serum human chorionic gonadotrophin and its subunits

We studied the dynamics of serum human chorionic gonadotrophin(HCG) and its free (HCG) and (HCGP) subunits in 49 early pregnanciesachieved by in-vitro fertilization (IVF) and embryo transfer.Of the 49 early pregnancies, nine were normal singleton pregnancies,11 were twin pregnancies, 11 were ectopic, eight ended in aclinical (spontaneous) abortion and 10 ended in a preclinicalabortion. The HCG, HCGa and HCGP concentrations in serum weremeasured on days 12, 19 and 26 after embryo transfer. Most ectopicpregnancies could be distinguished from singleton (and twin)pregnancies on the basis of low HCG concentrations by 12 daysafter embryo transfer, but clinical abortions could not be distinguishedfrom singleton pregnancies. In general, the measurement of HCGaand HCG and the molar ratios of the various forms provided onlymarginal additional value to that obtained from HCG, but ondays 19 and 26 after embryo transfer HCGa was the most sensitiveindicator of a normal pregnancy after IVF and embryo transfer.We conclude that in ectopic pregnancies the concentrations ofHCG, HCGa and HCGP increase as expected but 1.5 days later thanin normal pregnancies. This appears to be the result of a delayin implantation.     

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.     

Primary peritoneal pregnancy implanted on the uterosacral ligament: a case report

Peritoneal pregnancies are classified as primary and secondary. Primary implantation on the peritoneum is extremely rare in extrauterine pregnancy and is a potentially life-threatening variation of ectopic pregnancy within the peritoneal cavity, representing a grave risk to maternal health. Secondary abdominal pregnancies are by far the most common and result from tubal abortion or rupture, or less often, after uterine rupture with subsequent implantation within abdomen. Early diagnosis and appropriate surgical management, regardless of stage of gestation, appear to be important in achieving good results. We report a case of primary peritoneal pregnancy in a 28-year-old woman, who had severe lower abdominal pain one day before laparotomy for a preoperative diagnosis of ectopic pregnancy. The conceptus was implanted on the left uterosacral ligament. A fresh embryo of approximately 8 weeks' gestation was found in the conceptus.     

Serum markers in the diagnosis of tubal pregnancy

The introduction of highly sensitive methods, such as transvaginal sonography and measurement of serum b-human chorionic gonadotropin, has dramatically improved ectopic pregnancy diagnosis in recent years. Early diagnosis is the key to successful and conservative management of women with ectopic pregnancy; however, approximately 50 percent of such women are initially misdiagnosed, resulting in significant morbidity and mortality. In order to improve diagnosis, several serum markers are being investigated including progesterone, CA 125, pregnancy-associated plasma protein-A, vascular endothelial growth factor, and maternal creatine kinase. Measurement of serum vascular endothelial growth factor, alone or together with other markers, could be a promising method for earlier and more accurate differential diagnosis. However, the clinical applicability of these findings remains to be evaluated in larger prospective studies.     

Conventional B-mode and transvaginal color Doppler in ultrasound assessment of ectopic pregnancy

The study was arranged in two parts. In the first part, 43 of the clinically suspected ectopic pregnancies were sent for a transvaginal color Doppler examination. Both cystic and complex adnexal masses were carefully scanned for their Doppler flow characteristics. The Pourcelot index (RI) was calculated and the RI 0.40 was used as a cut-off point to differentiate the trophoblastic (RI less than 0.40) and the normal blood flow (RI greater than 0.40). The diagnosis was confirmed by the beta hCG serum test. Three false-negative and one false-positive findings were obtained. The transvaginal color and pulsed Doppler study of the flow within ectopic pregnancy has a high degree of sensitivity (87.5%), specificity (94.7%) and accuracy (90.7%). Pelvic sonograms of another 110 patients with proven ectopic pregnancy were reviewed retrospectively. The ectopic gestational sac with the alive embryo was documented in 11.8% cases and without the embryo in 30.4% cases. A mixed, solid or cystic adnexal mass was detected in 57.8% patients. Intrauterine findings showed a pseudogestational sac in 13.6% cases, a cluster configuration in 18.6% cases and a linear configuration in 67.8% cases. Criteria for the ultrasound diagnosis of ectopic pregnancy influencing its specificity, sensitivity and accuracy are discussed.     

Timed sequential analysis of creatine kinase in the diagnosis of myocardial infarction in patients over 65 years of age.

AIM--To assess the value of timed sequential analysis of creatine kinase (CK) activity for the early diagnosis of acute myocardial infarction (AMI) in patients over 65 years of age. METHOD--Samples were collected on admission and eight to 12 hours later from 156 patients over 65 years of age. Routine cardiac enzyme activities were determined and serial electrocardiograms (ECGs) recorded. The predictive value of timed samples for CK activity, standard cardiac enzyme activities, and ECGs was compared with the final diagnosis on discharge. RESULTS--Forty one patients had a discharge diagnosis of AMI, 83 of angina pectoris, and the remaining 32 patients had other diagnoses. Electrocardiograms had a sensitivity of 55% and a specificity of 96%, giving a predictive value of 86% for a negative and 84% for a positive ECG. Standard cardiac enzymes had a predictive value of 99% for a negative result but only 68% for a positive result. The logarithm of the rate of change of CK activity had a predictive value of 97% for a negative result and 95% for a positive result. CONCLUSION--This study has shown that slope analysis of CK activity can be used for the early diagnosis of AMI in patients over 65 years of age, and that this was not affected by the presence of possible confounding diagnoses.