Diagnosis and management of ectopic pregnancy

Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. The condition is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should perform a pregnancy test. If the patient is pregnant, the physician should perform a work-up to detect possible ectopic or ruptured ectopic pregnancy. Prompt ultrasound evaluation is key in diagnosing ectopic pregnancy. Equivocal ultrasound results should be combined with quantitative beta subunit of human chorionic gonadotropin levels. If a patient has a beta subunit of human chorionic gonadotropin level of 1,500 mIU per mL or greater, but the transvaginal ultrasonography does not show an intrauterine gestational sac, ectopic pregnancy should be suspected. Diagnostic uterine curettage may be appropriate in patients who are hemodynamically stable and whose beta subunit of human chorionic gonadotropin levels are not increasing as expected. Appropriate treatment for patients with nonruptured ectopic pregnancy may include expectant management, medical management with methotrexate, or surgery. Expectant management is appropriate only when beta subunit of human chorionic gonadotropin levels are low and declining. Initial levels determine the success of medical treatment. Surgical treatment is appropriate if ruptured ectopic pregnancy is suspected and if the patient is hemodynamically unstable.     

The conservative management of cervical ectopic pregnancies.

OBJECTIVE: To evaluate the role of conservative management in the treatment of cervical ectopic pregnancies. METHODS: This was a retrospective analysis of all cervical ectopic pregnancies diagnosed in women attending our early pregnancy unit between April 1997 and September 2004 inclusive. The diagnosis of cervical ectopic pregnancy was made using transvaginal ultrasound. Clinical and demographic data were recorded in all cases. Serum human chorionic gonadotropin levels were measured at presentation and monitored subsequently to determine the rate of successful resolution. Conservative management was in the form of medical or expectant management. Medical management involved administration of systemic or intra-amniotic methotrexate, with or without intra-amniotic potassium chloride. Systemic methotrexate was either a single dose of 50 mg/m2 or an alternate-day regimen of methotrexate at 1 mg/kg (days 1,3,5) with folinic acid rescue (days 2,4,6). If intra-amniotic treatment was required, this was either 50 mg methotrexate or 5 mmol/L potassium chloride. RESULTS: Seven cervical ectopic pregnancies were diagnosed during the study period. Three cases were managed successfully with a single dose of methotrexate. One case was managed successfully using a multiple-dose methotrexate regimen. Another case failed medical management with both the single- and multiple-dose regimens but was successfully treated after potassium chloride was given intra-amniotically under ultrasound guidance. One case was successfully treated with intra-amniotic methotrexate and another was managed expectantly. There was no associated morbidity or mortality during the study period. We also performed a review of the current literature. CONCLUSION: The conservative management of cervical ectopic pregnancy is effective and safe.     

The decidua-chorionic sac: a reliable sonographic indicator of intrauterine pregnancy prior to detection of a fetal pole.

Morphologically, the uterus in early intrauterine pregnancy, unlike ectopic pregnancy, contains both decidua and a chorionic sac. In view of this fact, a prospective study was performed to determine the accuracy of the demonstration of an intrauterine decidua-chorionic sac (DCS) in differentiating early or small intrauterine pregnancies (IUPs) without a demonstrable fetal pole from the intrauterine findings of ectopic pregnancy. The DCS was seen in 78 patients with proven IUPs and was not present in 52 consecutive patients with proven ectopic pregnancy (100 per cent accuracy). The decidua-chorionic sac is defined, and its relationships to the "double sac," double decidual sac, pseudosac, "crescent," pseudogestational sac, and the discriminatory human chorionic gonadotropin zone are discussed.     

Ectopic pregnancy. Diagnosis by sonography correlated with quantitative HCG levels

Pelvic sonograms were correlated with simultaneous human chorionic gonadotropin (HCG) determinations in 150 women with early intrauterine pregnancy (N = 76) and ectopic pregnancy (N = 74). Of the 76 patients with intrauterine pregnancy (IUP), 55 had HCG levels exceeding 1,800 mIU/ml (Second International Standard), and in each case a gestational sac was identified. In comparison, 35 of 74 (47%) patients with ectopic pregnancy had HCG levels of 1,800 mIU/ml or more, and no case demonstrated a gestational sac. Although six patients (8%) with ectopic pregnancy demonstrated a "pseudogestational sac," no case was confused with a true gestational sac. We conclude that, when the HCG level exceeds 1,800 mIU/ml, an intrauterine gestational sac is normally detected and its absence is evidence for an ectopic pregnancy.     

The problematic first-trimester pregnancy

The first-trimester obstetric patient who is experiencing pain or bleeding may have a normal intrauterine pregnancy, a threatened miscarriage, an ectopic pregnancy, a blighted ovum or trophoblastic disease. Correlation of clinical findings, quantitative human chorionic gonadotropin levels and diagnostic ultrasound findings can maximize the efficiency of the work-up, provide a definitive prognosis and identify early ectopic pregnancy.     

Ectopic pregnancy

Ectopic pregnancy occurs at a rate of 19.7 cases per 1,000 pregnancies in North America and is a leading cause of maternal mortality in the first trimester. Greater awareness of risk factors and improved technology (biochemical markers and ultrasonography) allow ectopic pregnancy to be identified before the development of life-threatening events. The evaluation may include a combination of determination of urine and serum human chorionic gonadotropin (hCG) levels, serum progesterone levels, ultrasonography, culdocentesis and laparoscopy. Key to the diagnosis is determination of the presence or absence of an intrauterine gestational sac correlated with quantitative serum beta-subunit hCG (beta-hCG) levels. An ectopic pregnancy should be suspected if transvaginal ultrasonography shows no intrauterine gestational sac when the beta-hCG level is higher than 1,500 mlU per mL (1,500 IU per L). If the beta-hCG level plateaus or fails to double in 48 hours and the ultrasound examination fails to identify an intrauterine gestational sac, uterine curettage may determine the presence or absence of chorionic villi. Although past treatment consisted of an open laparotomy and salpingectomy, current laparoscopic techniques for unruptured ectopic pregnancy emphasize tubal preservation. Other treatment options include the use of methotrexate therapy for small, unruptured ectopic pregnancies in hemodynamically stable patients. Expectant management may have a role when beta-hCG levels are low and declining.     

未成熟卵体外成熟与体外受精妊娠胚胎移植14d血清人绒毛膜促性腺激素β亚单位水平的比较

背景:相关研究表明,体外受精与胚胎移植治疗妊娠后血清人绒毛膜促性腺激素β亚单位水平对妊娠结局有预测作用,未成熟卵体外成熟治疗妊娠后血清人绒毛膜促性腺激素β亚单位水平对妊娠结局的预测作用不详.目的:比较不孕症患者体外受精与胚胎移植和未成熟卵体外成熟治疗妊娠后血清人绒毛膜促性腺激素β亚单位水平,探讨血清人绒毛膜促性腺激素β亚单位水平对未成熟卵体外成熟治疗妊娠患者的预测价值.方法:采用回顾性分析的方法,以在本中心行未成熟卵体外成熟治疗后妊娠实验阳性的42例患者为研究组,同期行体外受精治疗后妊娠实验阳性的66例患者作为对照组,比较两组患者胚胎移植后第14天血清人绒毛膜促性腺激素β亚单位水平.结果与结论:胚胎移植后14 d,分别在研究组和对照组内,单、双胎妊娠患者血清人绒毛膜促性腺激素β亚单位水平差异均有显著性意义.血清人绒毛膜促性腺激素β亚单位水平≥ 800 U/L时,两组双胎妊娠的发生率均明显增高.提示血清人绒毛膜促性腺激素β亚单位水平对未成熟卵体外成熟治疗后妊娠患者的结局具有预测价值,未成熟卵体外成熟/体外受精妊娠胚胎移植14 d血清人绒毛膜促性腺激素β亚单位水平及其对妊娠结局的预测是相同的.     

Ectopic pregnancy: transvaginal color Doppler of trophoblastic flow in questionable adnexa.

The purpose of this study was to see if color flow Doppler measurements could aid in the positive diagnosis of ectopic pregnancy when no gestational sac can be seen in the adnexa. We examined 148 women with abdominal pain and suspected ectopic pregnancy by abdominal ultrasonography, followed by vaginal ultrasonography and color Doppler when the diagnosis was still uncertain. Seventy-three patients proved to have ectopic pregnancies. Color flow with low resistance and high velocity vascular signals were observed in complex adnexal masses and in some of the corpora lutea. The resistance index for ectopic trophoblast was 0.36 +/- 0.02 SD. Color Doppler had both positive and negative discrimination of adnexal masses (P = 10(-15). The resistance index for the corpora lutea was 0.48 +/- 0.04. A cutoff value of 0.40 or less is proposed as a diagnostic index for suspected trophoblast in the adnexa. In nine cases of ectopic pregnancy, no color flow was noted. In these women, the beta-human chorionic gonadotropin level was less than 1000 mIU/ml. The clinical operative suspicion in these cases was tubal abortion. Sensitivity and specificity were 88% and 97%, respectively, in this highly selective series. Positive and negative predictive values were 97% and 89%. Color Doppler appears to be useful for the positive diagnosis of ectopic pregnancy with ultrasonography when no adnexal gestational sac is observed. Prospective randomized trials will determine the ultimate clinical value of these findings.     

联合应用垂体后叶素与肾上腺素对腹腔镜下输卵管妊娠开窗取胚术的价值

目的 探讨不同预处理方法运用于腹腔镜下输卵管妊娠开窗取胚术的安全性及可行性.方法 回顾性病例对照分析2014年10月-2018年10月120例在该院行腹腔镜下输卵管妊娠开窗取胚术的未破裂输卵管妊娠患者的临床资料,根据是否联合应用肾上腺素,将患者分为对照组(n=58)和观察组(n=62例).对照组在子宫角部偏后方与卵巢固...     

妊娠滋养细胞疾病误诊为异位妊娠三例临床分析及文献复习

目的探讨误诊为异位妊娠的妊娠滋养细胞疾病(gestational trophoblastic disease,GTD)患者的临床特点、诊治方法、误诊原因及防范措施。方法回顾性分析曾诊断异位妊娠、经术后病理检查确诊的GTD 3例临床资料。结果本组2例因急腹症就诊,经常规查体、超声及血人绒毛膜促性腺激素(HCG)和尿妊娠试验初诊为异位妊娠,经手术后病理检查确诊为输卵管绒毛膜癌和输卵管侵蚀性葡萄胎各1例;1例因下腹痛、自测尿妊娠试验阳性、突然晕倒诊断为异位妊娠,行左侧输卵管切除术后出现恶心呕吐、盆腔积血、血压升高,取手术标本病理会诊修正诊断为输卵管侵蚀性葡萄胎。3例确诊后经标准联合化疗治愈。结论特殊部位的GTD早期临床表现不典型,类似异位妊娠时易误诊,通过手术获取病理组织送检,重视监测血HCG变化,可避免延误诊治。     

异位妊娠药物保守治疗适应证的新评分法研究

目的 :探讨彩色多普勒超声 (CDFI)筛选适合药物保守治疗异位妊娠的临床价值。方法 :4 8例生命体征平稳的异位妊娠患者 ,在行CDFI检查后接受甲氨喋呤 (MTX) 5 0mg/m2 单次肌肉注射配合口服米非司酮 15 0mg ,随访直至临床结局。分析成功与失败病例CDFI的特点和绒毛膜促性腺激素 (hCG)水平 ,并制作CDFI评分。结果 :CDFI能直接反映胚胎生命力 ,CDFI图像和血清hCG水平不同者 ,保守治疗成功率有很大差异。结论 :CDFI评分可应用于适合保守治疗异位妊娠病例的筛选。对评分 >9者因失败率高 ,不推荐药物保守治疗。     

Review article: The use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding

Early pregnancy bleeding is a common presentation in the emergency setting. Traditionally, its assessment relied on clinical findings, including pelvic examination. However in recent years, ultrasonography and quantitative beta human chorionic gonadotropin assays have gained prominence and are now first‐line in diagnosing early pregnancy bleeding. Accordingly, the role of pelvic examination in the acute setting has been increasingly questioned. This article reviews the evidence for the role of pelvic examination in the assessment of early pregnancy bleeding in the ED. A Medline search was conducted and 43 articles were included in this review. Applicable research is largely observational and of a low level of evidence. However, available data indicate that the role of pelvic examination in the assessment of early pregnancy bleeding is limited, providing that there is prompt access to transvaginal ultrasound examination. Pelvic examination does not provide further diagnostic information over ultrasonography used in conjunction with beta human chorionic gonadotropin assays. The routine use of pelvic examination is not supported by the literature. However, when ultrasonography and beta human chorionic gonadotropin testing are unavailable or the results inconclusive, pelvic examination should be considered. Assessment in these instances must focus on identifying possible life‐threatening conditions, such as ectopic pregnancy, as well as determining the safety of discharge pending definitive assessment. Speculum examination is indicated in those presenting with severe bleeding or hypotension as removal of obstructing endocervical products can be a crucial resuscitative measure.     

The conservative management of early pregnancy complications: a review of the literature.

Early pregnancy complications include miscarriage, ectopic pregnancies, adnexal masses and pregnancies of unknown location. In this review, we evaluate the role of conservative management in these complications. We also evaluate the role of transvaginal sonography for diagnosis, treatment and follow up.When managing women with early pregnancy complications, it is important to recognise the normal sonographic milestones in the first trimester. Understanding the pattern of serum human chorionic gonadotropin change in early normal pregnancy and the correlation between low serum progesterone levels and the spontaneous resolution of a pregnancy are also important concepts.Guidelines for assessing suitability for conservative management should be strictly governed by evidence based protocols. Women can then be offered expectant or medical treatment as appropriate.     

血清标志物孕酮、β-HCG、E2和INHA在孕6周异位妊娠诊断中的价值

目的探讨β人绒毛膜促性腺激素(β-HCG)、孕酮、雌二醇(E2)、抑制素A(INHA)、游离β人绒毛膜促性腺激素(F-β-HCG)、妊娠相关血浆蛋白A(PAPP-A)、糖类抗原125(CA125)、甲胎蛋白(AFP)8项血清标志物及联合检测在异位妊娠早期诊断中的价值。方法随机选取2018年8-10月就诊于该院并确诊为异位妊娠患者68例、宫内妊娠流产患者100例、正常宫内妊娠患者100例分别作为异位妊娠组、宫内妊娠流产组和对照组。检测3组人群8项血清标志物的水平,研究其水平变化趋势;计算受试者工作特征曲线(ROC曲线)的曲线下面积(AUC),确定截断值并评价各血清标志物及联合检测的诊断效能。结果异位妊娠组与对照组8项血清标志物比较,差异均有统计学意义(P<0.05);宫内妊娠流产组与对照组比较,只有孕酮和E2水平差异有统计学意义(P<0.05)。比较各标志物ROC曲线的AUC值,发现在异位妊娠诊断中,诊断价值由高到低的顺序依次为孕酮、E2、INHA、β-HCG、F-β-HCG、PAPP-A、CA125、AFP。其中效能较高的前4项血清标志物联合检测,其AUC可达到0.970,灵敏度可达到86.8%,特异度为98.0%。孕酮、E2、INHA、β-HCG 4项检测在异位妊娠早期孕6周左右诊断中具有重要的临床价值,分别以孕酮15.02ng/mL,E2221.00pg/mL,INHA 17.25pg/mL,β-HCG 1285.00mIU/mL作为截断值。结论为提高异位妊娠早期诊断的正确率,建议采用孕酮、E2、INHA、β-HCG 4项联合检测方式来提高诊断效能。     

Ultrasonographic appearance of cervical pregnancy following successful treatment with methotrexate.

We report a case of cervical ectopic pregnancy successfully treated with systemic methotrexate. Conservative management with single-dose methotrexate was undertaken, but owing to the failure of human chorionic gonadotropin (hCG) levels to fall by 15% by day 7 and the persistence of fetal cardiac activity, two further doses of methotrexate were required. The patient's hCG levels were monitored, and repeat transvaginal ultrasonography was performed until complete resolution of the pregnancy by spontaneous miscarriage. We describe the ultrasonographic findings, which showed that the sac size increased despite treatment.     

The effectiveness of non-surgical management of early interstitial pregnancy: a report of ten cases and review of the literature.

OBJECTIVE: To assess the effectiveness of non-surgical management of interstitial pregnancy. DESIGN: A prospective interventional study. SUBJECTS: Eleven women with the ultrasound diagnosis of interstitial ectopic pregnancy. METHODS: Women with suspected early pregnancy complications were examined by transvaginal ultrasound. Those with the diagnosis of interstitial pregnancy were offered non-surgical treatment with methotrexate, which was administered systemically or by local injection. Follow-up with regular measurements of beta-human chorionic gonadotropin and ultrasound scans continued until the pregnancy had resolved completely. RESULTS: Ten women were managed non-surgically, and one woman opted for surgery. Five women received systemic and five local methotrexate. Local therapy was successful in all five cases (100%), whereas four out of five (80%) women receiving systemic methotrexate were cured. Significant side-effects were noted in two women following systemic therapy. In comparison, there were no side-effects in the group of women who received local therapy. There were no significant differences between the two treatment groups in the length of time taken for the pregnancy to resolve. CONCLUSIONS: Non-surgical treatment of interstitial pregnancy with methotrexate appears to be safe and effective. Local administration appears to be more successful and better tolerated by patients and may be used as the first-line therapy.     

输卵管妊娠的治疗现状与进展

输卵管妊娠是妇科常见急腹症,?其临床表现多样,并与病变部位密切相关;腹腔镜、高灵敏度的血清β-HCG检测以及经阴道超声探查等诊断水平提高,为输卵管妊娠治疗提供了更安全有效的治疗方法;药物治疗和手术治疗仍是输卵管妊娠治疗的主要手段,但手术观念已由积极追求妊娠病灶全切除向更好的术后生育功能保护方面发展。     

来曲唑联合绒促性素治疗多囊卵巢综合征患者的临床效果

目的 探讨来曲唑联合绒促性素治疗多囊卵巢综合征(PCOS)患者的临床效果.方法 选取2018年5月至2020年5月本院70例PCOS患者作为研究对象,按照随机数字表法将其分为对照组与观察组,每组35例.对照组采用氯米芬联合绒促性素治疗,观察组采用来曲唑联合绒促性素治疗.比较两组的性激素水平、子宫体积、子宫内膜厚度、排卵...     

Management of ectopic pregnancy

Risk factors for ectopic pregnancy include previous ectopic pregnancy, current intrauterine device use, prior fallopian tube surgery, previous pelvic inflammatory disease and a prior history of infertility. Abdominal pain is the most common symptom, followed by amenorrhea or vaginal bleeding, nausea, vomiting, syncope and dizziness. Referred shoulder pain following the onset of abdominal pain is characteristic of intraperitoneal bleeding and, in the appropriate clinical setting, strongly suggests a ruptured ectopic pregnancy. A coordinated evaluation includes measurement of serum human chorionic gonadotropin concentration and transabdominal or, preferably, transvaginal ultrasonography. Treatment is primarily by one of a variety of surgical techniques. Medical therapy with methotrexate or other drugs is currently under investigation.     

Progesterone as a predictor of ectopic pregnancy when the ultrasound is indeterminate

The objective of this study was to evaluate a progesterone cutpoint of 5.0 ng/mL ability to identify abnormal pregnancy (abnormal intrauterine pregnancy and ectopic pregnancy) as well as ectopic pregnancy alone in 2 subclasses of indeterminate ultrasounds. This was a prospective observational study of emergency department patients with abdominal pain or vaginal bleeding and an indeterminate transvaginal ultrasound. Two subclasses of indeterminate ultrasounds were eligible: those with an empty uterus and a beta-human chorionic gonadotropin value <3,000 mIU/mL and those with a nonspecific fluid collection. Patients were enrolled if a progesterone assay was collected the day of the emergency department visit. Patients were excluded if lost to follow-up. One hundred sixty patients were enrolled. Of these, 24 were diagnosed with ectopic pregnancy. The sensitivity and specificity of progesterone identifying abnormal pregnancy were 84% and 97%, respectively. The sensitivity and specificity of progesterone identifying ectopic pregnancy were 88% and 40%, respectively. In the 2 subclasses, the progesterone cutpoint was both sensitive and specific in identifying abnormal pregnancy and was sensitive but only moderately specific for identifying ectopic pregnancy.