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.     

Serum vascular endothelial growth factor as a possible marker for early ectopic pregnancy

BACKGROUND: This study evaluated serum vascular endothelial growth factor (VEGF) concentrations in women with normal intrauterine pregnancy (IUP), arrested IUP and ectopic pregnancy (EP). METHOD: This was a prospective, case-control study evaluating serum VEGF concentrations among 45 early pregnant women who subsequently were found to have an EP, a normal IUP or an arrested IUP (15 women in each group). Patients were stratified according to serum VEGF concentrations above and below 200 pg/ml. RESULTS: There was a significant difference in VEGF concentrations among women with EP, arrested IUP and normal IUP (306.1 +/- 26.5, 169.7 +/- 16.6 and 27.0 +/- 4.4 pg/ml respectively, P < 0.001). With a cut-off concentration of 200 pg/ml, serum VEGF could distinguish normal IUP from EP with a sensitivity of 88%, a specificity of 100% and a positive predictive value of 100%. Between EP and arrested IUP, the sensitivity was 87.5%, specificity 75% and positive predictive value of 77.8%. CONCLUSIONS: VEGF is a potential marker for EP. Its concentrations in women with EP are higher than in those with normal and arrested IUP.     

Choriocarcinoma-like human chorionic gonadotrophin (HCG) and HCG bioactivity during the first trimester of pregnancy

The objective of this study was to evaluate the distribution of choriocarcinoma-like human chorionic gonadotrophin (HCG) isoforms during first trimester pregnancy and their relationship with in-vitro HCG bioactivity. This was done by means of a retrospective analysis of patients' sera with first trimester normal intrauterine and abnormal (ectopic) pregnancies. Serum samples were obtained from 38 women with an amenorrhoea of <10 weeks. From these, 19 had a normal intrauterine pregnancy (IUP) and 19 an ectopic pregnancy (EP). Total immunoreactive HCG (HCGi), free beta-HCGi and oestradiol were measured by enzyme immunoassays and bioactive HCG by the mouse Leydig cell bioassay. The alterations in HCG isoform content were measured by the combination of two immunometric assays, B152 for choriocarcinoma-like HCG and B109 for intact HCG detection and expressed as the B152/B109 ratio. Choriocarcinoma-like HCG isoforms ratio measured by B152 and B109 assays was significantly higher in the low subgroups of free beta-HCGi and gestational age (P = 0.0111 and 0.0036 respectively). Whereas bioactive to immunoreactive HCG ratios (b/i ratio) were significantly higher when free beta-HCGi concentrations were low (P = 0.0010), no correlation was found between the variation of bioactivity (b/i ratio) and the proportion of choriocarcinoma-like HCG isoforms (B159/B108). It is concluded that in first trimester pregnancies (i) the modulation of HCG in-vitro bioactivity is not related to the variation of choriocarcinoma-like HCG isoforms secretion and (ii) the amount of choriocarcinoma-like HCG isoforms secreted by the early trophoblast is predominant and may be the result of an early developmental regulation of glycosylation enzyme.     

Vascular endothelial growth factor (VEGF) and discrimination between abnormal intrauterine and ectopic pregnancy

BACKGROUND: This study evaluated serum vascular endothelial growth factor (VEGF) levels in women with abnormal intrauterine and ectopic pregnancies (EP) at 6 weeks gestation. METHODS: We conducted a prospective case-control study comparing serum VEGF concentrations among 84 women with abnormal intrauterine and EP matched for gestational age (42 women in each group). We analysed whether serum VEGF levels >200 pg/ml would discriminate between abnormal intrauterine pregnancies and EP at 6 weeks gestation, and we calculated sensitivity, specificity and positive predictive values. RESULTS: Serum VEGF concentrations did not show statistically significant differences between women with abnormal intrauterine pregnancies (median, 198.5 pg/ml; range, 0-701.6) and EP (median, 211.2 pg/ml; range 0-628.8). When threshold concentrations of a serum VEGF level >200 pg/ml were used, abnormal intrauterine pregnancy could be distinguished from EP with a sensitivity of 56%, a specificity of 51%, and a positive predictive value of 53%. CONCLUSIONS: VEGF does not discriminate ectopic from abnormal intrauterine pregnancies at 6 weeks gestation, and thus should not be used in clinical management.     

Pregnancy-associated plasma protein A in pregnancy-related gynaecologic emergency

Serum concentrations of pregnancy-associated plasma protein A (PAPP-A) were measured in patients with pregnancy-related gynaecologic emergencies including ectopic pregnancy (n = 124) and intrauterine abortion (n = 40). The results were compared with those in normal pregnancy (n = 136) and non-pregnant women (n = 460). In ectopic pregnancy and intrauterine abortion, the PAPP-A levels were lower than in normal pregnancy. In patients with a pregnancy-related gynaecologic emergency PAPP-A was undetectable in 82% of the ectopic pregnancies and in 55% of the intrauterine abortions. Considering the frequency of ectopic pregnancy (35.8%) and intrauterine abortion (52.3%) among all patients with pregnancy-related disorders, the likelihood that a pregnant patient with undectable PAPP-A has an ectopic pregnancy is 30%, and intrauterine abortion is 29%. These results indicate that although PAPP-A levels in ectopic pregnancy and intrauterine abortion are lower than in normal pregnancy, PAPP-A measurement cannot be used to distinguish between ectopic pregnancy and intrauterine abortion.     

Activin A and Follistatin as Biomarkers for Ectopic Pregnancy and Missed Abortion

Activin A as a predictor of pregnancy failure has been the focus of heated debate, but the value of a combined activin A and follistatin (FS) measurement in serum to predict pregnancy failure has not been reported yet. We assessed whether a single serum measurement of the two physiological antagonists at 6–8 weeks gestation could differentiate ectopic pregnancies (EP) or missed abortions (MA) from healthy intrauterine pregnancies (IUP). activin A concentrations were significantly lower in women with EP (n = 30, median value of 264 pg/mL) and women with MA (n = 30, median value of 350 pg/mL) compared to IUP (n = 33, median value of 788 pg/mL); P < 0.001. At a threshold value of 505 pg/mL, activin A had 87.9% sensitivity and 100% specificity and negative predictive value of 0.974 for discriminating an ectopic pregnancy from viable pregnancies. FS was able to discriminate IUP from EP (ROC curve P < 0.001) as was their ratio (ROC curve P = 0.008), but was unable to discriminate a MA from an EP. In EP, activin A did not correlate with beta HCG levels. The present findings support the thesis that activin A or FS could be considered promising biomarkers for the discrimination between an IUP and a failed pregnancy (MA or EP).     

Subsequent fertility for patients presenting with an ectopic pregnancy and having an intra-uterine device in situ.

Of 503 ectopic pregnancies (EP) dealt with surgically using conservative laparoscopic techniques, 153 (30.4%) occurred in patients with an intra-uterine device (IUD) in situ. Examination of the characteristics of the EP revealed that the fimbrial location was more frequent among patients with an IUD whereas a significantly higher proportion were located in the isthmus in the group of patients without an IUD. Whereas the condition of the tubal wall did not differ according to the presence or absence of an IUD, adhesions and obstructed or non-existent contralateral tubes were significantly less frequent among patients with an IUD in situ. Two hundred and twenty three patients desired pregnancy, 30 of whom had an IUD in situ when the EP was diagnosed. The subsequent fertility for these 30 patients with an IUD was shown by rates for intrauterine pregnancy (IUP), recurrent EP and infertility of 96.7, 3.3 and 0% respectively. These results were significantly better than those for women who had no IUD, the figures for this group being 59, 13.4 and 27.4%, respectively. The favourable prognosis was due solely to the fact that women with an IUD had far fewer negative antecedents and that the EP probably occurred due to impaired ciliary action which is reversible when the IUD is removed.     

Modulation of human chorionic gonadotrophin bioactivity during the first trimester of pregnancy

The objective of this study was to evaluate the bioactivity of human chorionic gonadotrophin (HCG) during first trimester pregnancy. This was done by means of a retrospective analysis of sera from patients with first trimester normal intrauterine and ectopic pregnancies. Serum samples were obtained from 38 women with amenorrhoea of <10 weeks. From these, 19 had a normal intrauterine pregnancy (IUP) and 19 an ectopic pregnancy (EP). Cases were allocated to either low serum immunoreactive HCG (HCGi), intermediate HCGi or high HCGi concentrations (HCGi <5000 mUI/ml, between 5000 and 40,000 mIU/ml and >40,000 mIU/ml respectively). HCGi and oestradiol were measured by enzyme immunoassays and bioactive HCG by the mouse Leydig cell bioassay. All results were analysed by analysis of variance and unpaired Student's t-test. There was a significant difference between bioactive to immunoreactive HCG ratios (b/i ratio) between the subgroups of low, intermediate and high HCGi concentrations. Lower b/i ratios were found when HCGi concentrations were high (HCG b/i mean +/- SEM: high subgroup, 0.33 +/- 0.07 versus low subgroup: 1.50 +/- 0.12; P < 0.0001). Furthermore, the b/i ratios were inversely correlated with oestradiol (P < 0.0001) and HCGi (P < 0.0001) concentrations but not with gestational age. There was no difference in the b/i ratios when comparing IUP with EP. It is concluded that, in first trimester pregnancies, there is a likely modulation of HCG bioactivity which is inversely correlated with HCGi and oestradiol concentration. The underlying mechanisms and their physiological relevance remain to be elucidated.      

Are pregnancy-associated plasma protein-A (PAPP-A) and CA 125 measurements after IVF-ET possible predictors of early pregnancy wastage?

Pregnancy-associated plasma protein-A (PAPP-A), a macromolecular glycoprotein of placental origin, was reported to be depressed in established ectopic pregnancies. CA 125 is a known marker for ovarian cancer found to be elevated during the first trimester of pregnancy and in women with pelvic inflammatory disease. The present study investigated the usefulness of these parameters to predict the outcome of pregnancy in asymptomatic patients with a positive pregnancy test after in-vitro fertilization and embryo transfer (IVF-ET). Blood samples (n = 159) were obtained at different periods of time post-ET from 39 women, 21 of whom experienced a normal pregnancy, 12 had an intrauterine abortion and six had an ectopic pregnancy. PAPP-A and CA 125 were measured by radioimmunoassays. From day 30 onwards in normal pregnancies, PAPP-A was significantly increased over non-pregnant controls. In the spontaneous abortion group, the levels of PAPP-A were significantly lower than in normal pregnancy but higher than in non-pregnant controls. In ectopic pregnancy, PAPP-A remained at the level of non-pregnant controls throughout the entire observation period. CA 125 was significantly increased in all types of pregnancy. However, in two cases of hyperstimulation followed by a normal pregnancy and in four cases of ectopic pregnancy with signs of peritoneal irritation (hydrosalpinx, ruptured ectopic or salpingitis) the levels of CA 125 were 15-50 times higher than in normal pregnancies.(ABSTRACT TRUNCATED AT 250 WORDS)     

Defective endovascular trophoblast invasion in the first trimester is associated with increased maternal serum ischemia-modified albumin

BACKGROUND: Ischemia-modified albumin (IMA), a protein elevated in cardiac ischemia, is also increased to supra-physiological levels in early normal pregnancy. This finding supports the hypothesis that normal trophoblast development is stimulated by a hypoxic intrauterine environment. The aim of this study was to examine whether first trimester IMA levels are further elevated with defective trophoblast development. METHODS: Prospective study of healthy women with singleton pregnancies undergoing nuchal translucency assessment at 11-14 weeks. First trimester maternal serum IMA concentrations in those subsequently developing pre-term pre-eclampsia (n = 19) were compared to randomly chosen controls with normal pregnancy outcome (n = 69). RESULTS: Median first trimester serum IMA concentrations were significantly higher in women who subsequently developed pre-eclampsia (median 126.5 kU/L, interquartile range (IQR) 114.33-134.36 kU/L) when compared to those with normal pregnancy outcome (median 115.01 kU/L, IQR 102.29-124.81 kU/L, P = 0.02). CONCLUSIONS: Maternal serum IMA levels are elevated in the first trimester in women with pre-eclampsia, a clinical manifestation of defective endovascular trophoblast development. This suggests that abnormally high intrauterine hypoxia and subsequent reperfusion oxidative damage may be associated with defective trophoblast development. First trimester serum IMA may be a potential biomarker for abnormal placental development.     

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.     

Lymphocyte Subsets and Autoantibodies in Pregnancies Complicated by Placental Disorders

PROBLEM: The survival of the fetoplacental unit might partly depend on down-regulation of rejection reactions. Pathological maternal cellular immune response mechanisms could therefore be of pathogenic importance in pregnancies complicated by placental disorders. METHOD: A flow-cytometric analysis of T-cell subsets and B-cell, as well as serological tests for anticardiolipin antibodies (aCL), antinuclear antibodies (ANA), and rheumatoid factor (RF) were done on 90 women with complicated pregnancies. The results were compared with that of nonpregnant women (n=5), and normal pregnant women (n=5) in the third trimester. RESULTS: Two women, suffering from severe preeclampsia and eclampsia respectively, had aCL on 12 and 13 units, respectively. ANA occurred in 11 patients with moderate and severe preeclampsia and intrauterine growth retardation. All women had negative RF tests. Within the CD4 T-helper subpopulations, the proportion of suppressor/inducer T-cell population (CD4+CD45RA+) significantly increased, while the memory and helper/inducer T-cells (CD4+CD45RO+ and CD4+CD29+) significantly decreased during normal pregnancy compared to nonpregnant controls. This deviation of CD4 subpopulations was not found, or was less pronounced, in complicated pregnancies. The proportion of cytotoxic T cells (CD8+S6F1+) was significantly reduced during normal pregnancy. This reduction was less pronounced in complicated pregnancies. CONCLUSION: Systemic immunological deviations toward suppression or decreased activity of the immunological response as seen in normal pregnancies, was not observed in preeclampsia, intrauterine growth retardation, intrauterine fetal death, and abruptio placentae. This lack of suppression or increased T-cell activity may have a primary pathogenic role in some women with a complicated pregnancy, or it may be secondary to the placental disorders.     

The influence of donated gametes on the incidence of hypertensive disorders of pregnancy.

Pregnancies achieved from oocyte, sperm or embryo donation are unique, since they have resulted from donor gametes that are immunologically foreign to the mother. Thus, studying the obstetric outcome of such pregnancies may shed some light on the pathophysiology of preeclampsia, particularly in women conceiving with donated embryos, since the entire fetal genome is allogenic in these pregnancies. In this retrospective cohort study, a total of 144 women were studied. Of these, 72 were infertility patients who had conceived as a result of sperm, ovum or embryo donation and the other 72 women were age- and parity-matched control patients who became pregnant with their own gametes, either spontaneously, or following intrauterine insemination with their partner's spermatozoa. Study patients were divided into three groups depending on the origin of the donated gametes. Group 1 consisted of pregnancies achieved by intrauterine insemination with washed donor spermatozoa (n = 33). Group 2 included women who conceived using donated oocytes (n = 27) and group 3 consisted of women who conceived as a result of embryo donation (n = 12). The incidence of pregnancy-induced hypertension in the donated gametes study group was 12.5% (9/72) compared with 2.8% (2/72) in the control group. In addition, pre-eclampsia was diagnosed in 18.1% (13/72) of the donated gametes study group compared to 1.4% (1/72) in the age- and parity-matched controls. The increased incidence of gestational hypertension in pregnancies resulting from donated gametes gives evidence for a maternal genetic component, with an equally strong fetal influence, in the complicated aetiology of gestational hypertension, and pre-eclampsia in particular.     

Reproductive outcomes of women with a previous history of Caesarean scar ectopic pregnancies

BACKGROUND: Caesarean scar ectopic pregnancy is associated with a number of significant complications. In this study, we report on subsequent reproductive outcomes in a group of women following successful treatment of their scar pregnancies. METHODS: The study included those women who received treatment for their Caesarean scar pregnancies between April 1999 and October 2005. Their ability to conceive, the time it took to become pregnant and outcomes of subsequent pregnancies were all recorded. RESULTS: 40 women with Caesarean scar pregnancies were managed in our unit. The uterus was conserved in 38/40 cases. Follow-up data were available in 29/38 (76%) of women. Twenty-four out of 29 (83%) attempted to become pregnant. Twenty-one out of 24 [88%, 95% confidence interval (CI): 75-100] women conceived spontaneously. Twenty out of 21 (95%, 95% CI: 86-100) pregnancies were intrauterine and one woman (5%, 95% CI: 0-14) had a recurrent scar ectopic. Thirteen out of 20 (65%, 95% CI: 44-86) intrauterine pregnancies appeared normal. Nine out of 13 (69%) were delivered by Caesarean section. Seven out of 20 (35%, 95% CI: 14-56) intrauterine pregnancies ended in spontaneous abortions. CONCLUSIONS: Our study shows that reproductive outcomes following treatment of caesarean scar ectopic pregnancies are favourable. The risk of complications including recurrent scar implantation appears to be low.     

Pregnancy: Placental isoferritin patterns during normal first trimester and tubal gestations

Placental isoferritin (PLF) has been shown to be involved inthe down-regulation of the maternal immune system during pregnancy.In a prospective study, serum PLF concentrations were measuredin 33 pregnant women with singleton, normal, ongoing first trimestergestations and compared with those of 22 women with tubal gestations.Diagnoses were based on endocrinological, sonographic, intra-operativeand histopathological criteria. Venous blood was obtained fromboth groups for PLF determination before evacuation of the pregnancyproducts. B-Human chorionic gonadotrophin (HCG), 17B-oestradioland progesterone were determined at surgery for the tubal pregnancypatients. The mean ± SD PLF concentrations were 18 ±14, 25.4 ± 42.3 IU/ml among normal and tubal gestationsrespectively. Significant differences between normal and tubalpregnancies were found (P < 0.05). Based on PLF measurements,sensitivity (67%) and specificity (33%) values were found tobe similar for the normal and ectopic pregnancies. No correlationwas found between the other measured pregnancy hormones andPLF for the tubal pregnancy group. Low PLF concentrations amongpathological gestations may reflect abnormal trophoblastic activity.The simultaneous assessment of PLF and -HCG concentrations whichprobably originate from different trophoblastic cells, is recommendedfor better diagnosis and monitoring of first trimester placentalactivity.     

Salpingectomy - the laparoscopic surgical choice for ectopic pregnancy

The aim of this study was to assess the fertility outcome afterectopic pregnancy (EP) treated by laparoscopic salpingectomy.Among the 375 patients who underwent this operation betweenJanuary 1983 and December 1993, there were 145 patients whodesired pregnancy and whose contralateral tube was not obstructed.The overall rate of intrauterine pregnancy (IUP) was 50.3%,with an EP rate of 15.2%, These results were analysed accordingto the patients‘ past history together with the conditionof the contralateral tube at the time of the laparoscopy. Wedefined two groups. Group 1 included patients who had no previoushistory of tubal surgery and whose contralateral tube was normal.Group 2 comprised those patients who had a previous historyof tubal surgery and/or those whose tube was pathological, butnot obstructed. Postoperative fertility of the patients in group1 was significantly higher than that of the patients in group2, with IUP rates of 75 and 36.6% respectively (P < 0.001),and a risk of EP recurrence of 9.6 and 183% respectively. Ingroup 1, the actuarial IUP rate at 24 months was significantlyhigher than that for the patients in group 2 (66.7 versus 36.9%;P < 0.001). The patient’s past history and the conditionof the contralateral tube were the two major factors relatedto fertility outcome after laparoscopic salpingectomy for EP.In patients with no past history of tubal surgery or infertilityand whose contralateral tube was normal, the fertility resultsafter laparoscopic salpingectomy appeared comparable to thoseobserved after conservative laparoscopic treatment     

Ovarian stimulation in intrauterine insemination with donor sperm: a randomized study comparing clomiphene citrate in fixed protocol versus highly purified urinary FSH

BACKGROUND: The study was conducted to compare the results of intrauterine donor insemination (DI) under ovarian stimulation with either clomiphene citrate (CC), in a fixed protocol, or FSH, with ovarian monitoring. METHODS: Forty-nine patients were randomized using a computer-generated list to receive highly purified urinary FSH (starting dose of 150 IU) and were subjected to periodic vaginal ultrasound and estradiol determinations. HCG was given when > or =2 follicles (> or =17 mm) were identified and estradiol reached >400 pg/ml. Intrauterine insemination (IUI) was performed 36 h later. The other 51 received CC on a fixed protocol (100 mg/day from the day 5-10 of the ovarian cycle) with HCG being administered on the day 12, and IUI performed 36 h later. Up to six IUI cycles were performed on all patients if pregnancy was not reached before. Women failing to conceive in the CC group underwent IUI with FSH. The main outcome measures were intrauterine gestational sac observed by transvaginal ultrasound, per cycle and per woman pregnancy rate (PR) and multiple PR. RESULTS: The per cycle PR was significantly higher in the FSH group, 14.4% (30/209) versus 6.1% (16/261), as well as the per woman PR, 61.2% (30/49) versus 31.4% (16/51). 12.5% (2/16) of pregnancies obtained in the CC group were multiple, compared with 20% (6/30) in the FSH group. There were no triplets or higher order pregnancies in CC versus two in FSH (6.7% of pregnancies). Patients failing to conceive with CC, who later underwent intrauterine DI with FSH, had similar results to the primary FSH group: 54.3% PR per patient (19/35) and 16.0% per cycle (19/118), with a multiple PR of 31.6% (6/19). The PR for women starting with CC cycles and, if pregnancy was not obtained, continuing with six FSH cycles, was 69.2%. CONCLUSIONS: The PR obtained with CC stimulation was approximately half that obtained with FSH. There was a trend to lower multiple PR with CC. It is recommended that each case should be considered on an individual basis and the treatment options discussed with patients. In our opinion, CC could be a reasonable approach for young women with good prognosis, whereas in the remaining cases FSH would be the preferable method.     

The occurrence and outcome of 39 pregnancies after 1621 cases of transcervical resection of endometrium

BACKGROUND: To evaluate the outcomes and management of pregnancy after transcervical resection of the endometrium (TCRE). METHODS: Retrospective study of 39 pregnancies after 1621 procedures of TCRE. RESULTS: Among 1621 women who were successfully followed up after TCRE, there were 39 pregnancies in 32 women, including five ectopic pregnancies (12.8%) and 34 intrauterine pregnancies (87.2%). The majority of pregnancies (84.6%) occurred within the first 2 years. In the first year after TCRE, the incidence of pregnancy was 1.5%. In women who had amenorrhoea after TCRE, the chances of conception (2/676; 0.3%) were significantly (P < 0.001) lower than for those who continued to have period (30/945; 3.2%). Thirty-two cases with intrauterine pregnancy were terminated under ultrasound guidance with two difficult procedures. Only one pregnancy in our study resulted in spontaneous miscarriage which was managed by suction curettage. One term pregnancy had placenta increta resulting in Caesarean hysterectomy. CONCLUSIONS: Pregnancies after TCRE are associated with increased risk, and clinicians should be aware of the various complications of pregnancy that may occur after TCRE, including an increased risk of ectopic pregnancy. Surgical termination of pregnancy after TCRE is potentially a difficult procedure and should be carried out under ultrasound guidance.     

Fertility outcome after ectopic pregnancy and use of an intrauterine device at the time of the index ectopic pregnancy

Fertility after ectopic pregnancy (EP) was investigated in a non-selected population taking into account intrauterine device (IUD) use at the time of the EP. Between January 1992 and June 1996, 647 women listed in the EP register of Auvergne (France) were followed up. The analysis included only the 328 women who were seeking to become pregnant: 23 women using IUD at the time of the index EP (IUD users) and 305 IUD non-users. Among IUD users, there was no recurrence of EP, and the 1 year cumulative rate was 87% [95% confidence interval (CI): 73-100%] for intrauterine pregnancies and 86% (95% CI: 72-100%) for deliveries. Among IUD non-users, the 2 year cumulative rate for recurrence of EP was 28% (95% CI: 17-39%), and the 1 year cumulative rates were 60% (95% CI: 53-66%) for intrauterine pregnancies and 44% (95% CI: 38-56%) for deliveries. The adjusted intrauterine pregnancy rate of IUD users was not significantly different from that of IUD non-users. However, IUD non-users had more miscarriages, so their delivery rate was lower.