Ultrasound versus culdocentesis in the evaluation of early and late ectopic pregnancy

A retrospective study of patients found to have ectopic pregnancy was undertaken to determine the relative usefulness of culdocentesis and ultrasound in the evaluation of early and late presentations. The patient's history was used as the sole determinant of gestational age, and results of culdocentesis and/or ultrasound were reviewed. In early presentations (less than 42 days gestation), 38% of ultrasound examinations and 89% of culdocenteses performed were positive. In late presentations, 93% of ultrasound examinations and 70% of culdocenteses performed were positive. The difference between the modalities' performance was significant (P less than .05) for both early and late presentations. These data could provide the basis for a prospective study to test the hypothesis that culdocentesis is the diagnostic test of choice in early suspected ectopic pregnancy, whereas ultrasound is more likely to yield clinically useful information in patients presenting after six weeks gestation.     

Rate of change of serial beta-human chorionic gonadotropin values as a predictor of ectopic pregnancy in patients with indeterminate transvaginal ultrasound findings

STUDY OBJECTIVE: To determine the predictive value of the rate of change of serial beta-human chorionic gonadotropin (hCG) values in patients with symptoms suggestive of ectopic pregnancy but who have indeterminate transvaginal ultrasound findings, and to determine whether the predictive value was enhanced depending on whether the endometrial cavity was empty at ultrasound examination. METHODS: A retrospective study was performed on consecutive emergency department patients from August 1, 1991, through August 1, 1998, presenting with abdominal pain or vaginal bleeding, a positive beta-hCG test result, and indeterminate transvaginal ultrasound findings. Patients were eligible for the study if they had a second beta-hCG assay performed within 7 days of the initial visit and before either a diagnostic dilation and evacuation or laparoscopy. Patients were excluded if they were lost to follow-up. Patients were divided into 4 groups based on the rate of change of beta-hCG values over a 48-hour interval (increase by >66%, increase by <66%, decrease by <50%, decrease by >50%). In addition, the 4 main groups were further subdivided depending on whether the endometrial cavity was empty at ultrasound examination. Intergroup differences in the frequency of ectopic pregnancy based on the rate of change of the beta-hCG value were compared using logistic regression. Logistic regression also was used to determine whether addition of the ultrasound result improved predicative accuracy. A P value of less than.05 was considered significant. Odds ratios (ORs) were determined for each subgroup. RESULTS: Three hundred thirty-one eligible patients were identified; of these, 24 were excluded. Of the 307 enrolled patients, 33 (10.7%) had a final diagnosis of ectopic pregnancy. Intergroup differences in the frequency of ectopic pregnancy based on the beta-hCG rate of change were significant (P<.0001). Addition of the ultrasound result to this model further improved predicative accuracy (P<.0001). Overall, patients with increasing beta-hCG values were at increased risk compared with those with decreasing beta-hCG values, and patients with empty uteri at ultrasound were at increased risk compared with those with uteri that were not empty. Combining the beta-hCG rate of change with the ultrasound result identified 3 high-risk groups: patients with beta-hCG values that increased by less than 66% and an empty uterus at ultrasound (OR 24.8); patients with beta-hCG values that decreased by less than 50% and an empty uterus at ultrasound (OR 3.7); and patients with beta-hCG values that increased by more than 66% and an empty uterus at ultrasound (OR 2.6). Patients with beta-hCG values that decreased by more than 50% were found to be at low risk for ectopic pregnancy irrespective of the specific endometrial findings at ultrasound. CONCLUSION: The rate of change of serial beta-hCG values, in patients with an indeterminate pelvic ultrasound examination, is predictive of ectopic pregnancy. Addition of whether the endometrial cavity is empty at ultrasound leads to a further improvement in predictive accuracy.     

Advances in pelvic ultrasound: Endovaginal scanning for ectopic gestation and graded compression sonography for appendicitis

Endovaginal sonography and graded compression sonography for appendicitis are two recent, significant advances in the imaging evaluation of the pelvis. Endovaginal sonography is performed by placing a dedicated high-frequency ultrasound probe within the vagina to evaluate the uterus and adnexa. Much early research with this technique has focused on the evaluation of early pregnancy, where changes related to intrauterine and ectopic gestation are evident at least one week earlier when compared with routine transabdominal ultrasound. Graded compression sonography for appendicitis is an ultrasound search for the inflamed, nonruptured appendix performed by compressing the right lower quadrant with a linear array transducer. Both techniques are fast, safe, and inexpensive evaluations that can be used to evaluate patients with nonspecific clinical findings and are particularly helpful in women of childbearing age.     

Subclassification of indeterminate pelvic ultrasonography: prospective evaluation of the risk of ectopic pregnancy

STUDY OBJECTIVE: We sought to determine the frequency of ectopic pregnancy among subclasses of indeterminate ultrasonographic examinations. METHODS: A prospective observational study was performed from January 1, 1995, to August 31, 2000, on consecutive emergency department patients in the first trimester of pregnancy with a chief complaint of abdominal pain or vaginal bleeding and who had an indeterminate transvaginal ultrasonographic examination at the time of the ED visit. Patients were excluded if lost to follow-up. Ultrasonographic examinations were subclassified into 5 groups (ie, empty uterus, nonspecific fluid, echogenic material, abnormal sac, normal sac) on the basis of a previously published classification system. Patients were followed up until the diagnosis of ectopic pregnancy was either confirmed or excluded. The frequencies of ectopic pregnancy, along with 95% confidence intervals (CIs), were calculated for each of the subclasses. The relative risk of ectopic pregnancy was calculated when appropriate. RESULTS: Seven hundred eighty patients with indeterminate ultrasonographic examinations were identified. One hundred forty-five were lost to follow-up, and therefore, 635 were enrolled. The frequency of ectopic pregnancy for each subclass is as follows: empty uterus, 36 of 259 (13.9%; 95% CI 10.1% to 18.5%); nonspecific fluid, 6 of 127 (4.7%; 95% CI 1.9% to 9.6%); echogenic material, 4 of 93 (4.3%; 95% CI 1.4% to 10.5%); abnormal sac, 0 of 103 (0%; 95% CI 0.0% to 2.9%); and normal sac, 0 of 53 (0%; 95% CI 0.0% to 5.5%). The relative risk of ectopic pregnancy in patients with an empty uterus versus in those without an empty uterus was 5.2 (95% CI 2.6 to 10.2). CONCLUSION: In our sample, patients with an empty uterus at ultrasonography had the highest frequency of ectopic pregnancy, with a relative risk of ectopic pregnancy 5 times greater than that of the other 4 subclasses.     

Ruptured interstitial pregnancy presenting as an intrauterine pregnancy by ultrasound.

Interstitial pregnancy is an uncommon subset of ectopic pregnancy in which the conceptum implants in the intrauterine portion of the fallopian tube. These pregnancies tend to progress further before rupture than do other tubal pregnancies and subsequently have greater propensity for massive intra-abdominal bleeding and maternal demise. Abdominal ultrasound can be deceptive in evaluating interstitial ectopic pregnancies. Transvaginal ultrasonography is more sensitive in the diagnosis of early ectopic pregnancy. Knowledge of the application and limitations of both transabdominal and transvaginal ultrasound will assist the emergency physician in the timely evaluation of this potentially lethal condition.     

Rate of Change of Serial β–Human Chorionic Gonadotropin Values as a Predictor of Ectopic Pregnancy in Patients With Indeterminate Transvaginal Ultrasound Findings

Study objective: To determine the predictive value of the rate of change of serial β–human chorionic gonadotropin (hCG) values in patients with symptoms suggestive of ectopic pregnancy but who have indeterminate transvaginal ultrasound findings, and to determine whether the predictive value was enhanced depending on whether the endometrial cavity was empty at ultrasound examination. Methods: A retrospective study was performed on consecutive emergency department patients from August 1, 1991, through August 1, 1998, presenting with abdominal pain or vaginal bleeding, a positive β-hCG test result, and indeterminate transvaginal ultrasound findings. Patients were eligible for the study if they had a second β-hCG assay performed within 7 days of the initial visit and before either a diagnostic dilation and evacuation or laparoscopy. Patients were excluded if they were lost to follow-up. Patients were divided into 4 groups based on the rate of change of β-hCG values over a 48-hour interval (increase by >66%, increase by <66%, decrease by <50%, decrease by >50%). In addition, the 4 main groups were further subdivided depending on whether the endometrial cavity was empty at ultrasound examination. Intergroup differences in the frequency of ectopic pregnancy based on the rate of change of the β-hCG value were compared using logistic regression. Logistic regression also was used to determine whether addition of the ultrasound result improved predicative accuracy. A P value of less than .05 was considered significant. Odds ratios (ORs) were determined for each subgroup. Results: Three hundred thirty-one eligible patients were identified; of these, 24 were excluded. Of the 307 enrolled patients, 33 (10.7%) had a final diagnosis of ectopic pregnancy. Intergroup differences in the frequency of ectopic pregnancy based on the β-hCG rate of change were significant (P <.0001). Addition of the ultrasound result to this model further improved predicative accuracy (P <.0001). Overall, patients with increasing β-hCG values were at increased risk compared with those with decreasing β-hCG values, and patients with empty uteri at ultrasound were at increased risk compared with those with uteri that were not empty. Combining the β-hCG rate of change with the ultrasound result identified 3 high-risk groups: patients with β-hCG values that increased by less than 66% and an empty uterus at ultrasound (OR 24.8); patients with β-hCG values that decreased by less than 50% and an empty uterus at ultrasound (OR 3.7); and patients with β-hCG values that increased by more than 66% and an empty uterus at ultrasound (OR 2.6). Patients with β-hCG values that decreased by more than 50% were found to be at low risk for ectopic pregnancy irrespective of the specific endometrial findings at ultrasound. Conclusion: The rate of change of serial β-hCG values, in patients with an indeterminate pelvic ultrasound examination, is predictive of ectopic pregnancy. Addition of whether the endometrial cavity is empty at ultrasound leads to a further improvement in predictive accuracy. [Dart RG, Mitterando J, Dart LM: Rate of change of serial β–human chorionic gonadotropin values as a predictor of ectopic pregnancy in patients with indeterminate transvaginal ultrasound findings. Ann Emerg Med December 1999;34:703-710.]     

Cardiomyopathy and myocarditis in children with ventricular ectopic rhythm.

OBJECTIVE. The objective of this study was to evaluate the histologic features of the myocardium in children with abnormal ventricular ectopic rhythm but a structurally normal heart. BACKGROUND. Abnormal ventricular ectopic rhythm in children with a structurally normal heart is an uncommon but serious condition. Previous studies in adults with these findings have shown that approximately 10% have "primary electrical disease" and that 40% to 100% of these have abnormal histologic findings. METHODS. Endomyocardial biopsy samples were obtained prospectively in 33 subjects presenting with ventricular ectopic rhythm but a structurally normal heart by physical examination and noninvasive studies. Biopsy specimens were evaluated for histologic changes consistent with dilated cardiomyopathy or myocarditis and these results were compared with noninvasive and invasive clinical findings. RESULTS. Of the 33 subjects, 16 (48%) had normal myocardial histologic features (Group A), 14 (42%) had changes similar to the histologic features seen with idiopathic dilated cardiomyopathy (Group B) and 3 (9%) had lymphocytic myocarditis (Group C). Presenting clinical symptoms, surface electrocardiograms (ECGs), exercise stress testing and electrophysiologic stimulation tests failed to predict the biopsy results. Twenty-four-hour ambulatory ECGs showed a statistical difference between sustained and nonsustained ventricular tachycardia in Group A versus Group B (p less than 0.007), with Group A having more sustained ventricular tachycardia. Left ventricular function measured by fractional shortening on echocardiography did not differ between groups, but left ventricular end-diastolic dimension was greater in the subjects with abnormal histologic findings (Group B) (p less than 0.03). CONCLUSIONS. These results provide evidence that approximately 50% of children with abnormal ventricular ectopic rhythm but a structurally normal heart may have subclinical cardiomyopathy or unsuspected myocarditis.     

Emergency department diagnosis of ectopic pregnancy

STUDY OBJECTIVES: To assess the accuracy of the history and physical examination as compared to the addition of serum progesterone screening for ectopic pregnancy in women presenting to the emergency department. DESIGN: Prospective, consecutive case series, N = 2,157. SETTING: ED of the Regional Medical Center at Memphis, a publicly subsidized, 450-bed acute care hospital staffed by residents and faculty of the University of Tennessee, Memphis. TYPE OF PARTICIPANTS: All ED patients with a positive urine pregnancy test treated between January 1 and December 31, 1988. INTERVENTIONS: Screening history, physical examination, and serum progesterone (P) and quantitative human chorionic gonadotropin (hCG) titer. MEASUREMENTS: All discharged patients were given follow-up appointments within two weeks; those found to have a P less than 25 ng/mL were called to return for repeat hCG and transvaginal ultrasound. MAIN RESULTS: One hundred sixty-one of 2,157 patients (7.5%) with a positive urine pregnancy test were found to have an ectopic pregnancy. All but five had a P of less than 25 ng/mL (sensitivity, 97%); four of these were admitted for immediate surgery because of symptoms. Overall, the ED physician detected 89 of 161 ectopics (55.3%) on initial presentation, 53 (60%) of which were ruptured at the time of surgery. Seventy-two patients (44.7%) who were discharged but later found to have an ectopic pregnancy had benign clinical presentations, including 41 with vaginal bleeding. There were no statistically significant differences in the presenting symptoms of patients with unruptured ectopics compared with normal intrauterine pregnancies. All but one of the 72 discharged patients were noted the following day to have a progesterone of less than 25 ng/mL and contacted to return. Eight of these were found to have a ruptured ectopic at the time of surgery. Only 91 of 161 patients (56.5%) with ectopic pregnancy acknowledged one or more clinical risk factors on follow-up questioning. CONCLUSION: The standard history and physical examination, including those performed by gynecologic specialists, are insufficiently sensitive for early detection of unruptured ectopic pregnancy. EDs with a high incidence of ectopic pregnancy should strongly consider implementation of a universal progesterone screening program to decrease unnecessary patient morbidity and the risk of mortality from undiagnosed ectopic pregnancy.     

Interstitial pregnancy: a potential for misdiagnosis of ectopic pregnancy with emergency department ultrasonography

Interstitial pregnancy is a rare and dangerous form of ectopic pregnancy that can be mistaken for a normal intrauterine pregnancy on ultrasonography, leading to catastrophic results. Increasingly, emergency physicians are using ultrasonography to diagnose intrauterine pregnancy. Emergency physicians should be aware of the potential for mistaking an interstitial pregnancy for an intrauterine pregnancy. We present a case report of an interstitial pregnancy misdiagnosed as an intrauterine pregnancy and discuss ultrasonographic and physical examination findings to help differentiate interstitial pregnancy from an intrauterine pregnancy.     

Chlamydia trachomatis and ectopic pregnancy: recent epidemiological findings

PURPOSE OF REVIEW: Genital Chlamydia trachomatis is common among young, sexually active people. Infections are most often asymptomatic but have potential long-term consequences for female reproductive health. The link between C. trachomatis and ectopic pregnancy is mainly based on early seroepidemiological case-control studies including women who had their sexual debut at a time at which testing was sparse. The purpose of the present review is to summarize recent findings in C. trachomatis and ectopic pregnancy epidemiology. RECENT FINDINGS: The number of prevalence studies is high but results are specific for the setting in which the study was conducted. High prevalences are often found among adolescents and young adults. At the same time, decreased ectopic pregnancy rates are reported. Registry studies from the Scandinavian countries have shown low ectopic pregnancy rates among women tested for C. trachomatis and diverging results considering whether women are at increased risk following infection. SUMMARY: Recent studies on C. trachomatis infection and ectopic pregnancy are few. The recent Scandinavian registry studies include women with diagnosed, and hence presumably treated, infections. The observation of low complication rates in these studies cannot be used as an argument against the importance of screening for C. trachomatis infections.     

Tubal pregnancy after total vaginal hysterectomy

We report the case of a 26-year-old woman who presented to our emergency department for evaluation of abdominal pain 24 days after a vaginal hysterectomy. The patient's serum pregnancy test was positive. An ectopic pregnancy of the right adnexa was diagnosed by ultrasound and confirmed by laparotomy. The patient recovered uneventfully. Ectopic pregnancy after a total hysterectomy can occur if the fertilized ovum is in the fallopian tube at the time of the hysterectomy or if a fistulous tract exists between the vagina and the ovaries, enabling fertilization to occur. The diagnosis of ectopic pregnancy after a total hysterectomy is unusual yet must be considered in the presence of intact ovaries to avoid a delay in treatment.     

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.     

Liver ultrasound findings in a low prevalence area of S. japonicum in China: comparison with history, physical examination, parasitological and serological results.

The paper describes a study carried out in a community in Dongdian township, Anhui Province, People's Republic of China. Medical history and the results of a physical examination, ultrasound investigation, parasitological and serological tests for Schistosoma japonicum infection were compared in 661 persons of 169 households. A lack of correlation between parasitological and serological indicators of infection and morbidity was observed in this area of low (6.4%) prevalence and intensity of infection. The prevalence of abnormal ultrasound findings in the liver in this population was high (56%), and was significantly higher than the prevalence of S. japonicum infection. The abnormal ultrasound findings correlated with a history of schistosomiasis, and the correlation increased significantly according to the number of times treated and the time since the last treatment, which suggested that past parenteral treatment has a role in the high rate of abnormal liver ultrasound findings. The significant correlation between the qualitative and quantitative serological results and abnormal ultrasound parenchymal patterns suggests that cross-reactivity between the etiology of the parenchymal disease and these tests is occurring. The presence of HBsAg correlated with the composite presence of ultrasound abnormalities of the liver parenchyma: increased echogenicity, periportal fibrosis and/or nodules and irregular fibrosis, whereas a normal ultrasound pattern was associated with the absence of HBV antigenemia.     

DETECTION OF PROXIMAL-VEIN THROMBOSIS BY DOPPLER ULTRASOUND FLOW-DETECTION METHOD

Fifty patients with chronic swollen legs were investigated by the transcutaneous Doppler ultrasound flow-detection method and iliac phlebography. Thrombosis of the iliofemoral segment can be readily diagnosed by the alterations of audible sounds or flow velocity patterns recorded over the common femoral vein. Valsalva or Müller manœuvres had no effect on common femoral-vein blood-flow velocity if the iliac vein was completely occluded. Of fifteen patients with normal ultrasound findings, thirteen had normal patent iliac veins on iliac phlebography. Thirty-three patients who had abnormal ultrasound findings were found to have complete or incomplete iliac-vein thrombosis. Lymphangiograms on five patients with normal ultrasound and phlebographic findings established the diagnosis of lymphœdema. The use of the Doppler ultrasound method seems to be of special value in selecting patients with swollen limbs for radiological investigation.     

腹部超声与阴道超声对异位妊娠检出率对比分析

目的 探讨经腹部超声与经阴道超声在异位妊娠中的诊断价值.方法 选择2004-09～2012-03在该院和外院经手术和病理证实为异位妊娠的85例患者分别进行腹部超声检查和阴道超声检查,并对两种方法 检查结果 进行分析比较.结果 85例异位妊娠中,破裂流产型62例,未破裂型23例.经腹部超声检出80例,检出率为94.1%,其中破裂流产型62例,检出率为100%;未破裂型18例,检出率为78%.经阴道超声检出82例,检出率为96.5%,其中诊断破裂流产型59例,检出率为96%,未破裂型23例,检出率为100%.两种检查方法 检出率比较差异均无统计学意义(P均>0.05).经腹部和经阴道超声联合应用诊断异位妊娠85例,超声诊断符合率达100%.结论 经腹部超声诊断破裂流产型异位妊娠占优势,经阴道超声诊断未破裂型异位妊娠占优势.经腹部和经阴道超声联合运用,能取长补短,明显提高异位妊娠的检出率,具有较高的临床应用价值.     

Role of ERCP in asymptomatic orthotopic liver transplant patients with abnormal liver enzymes

OBJECTIVE: The safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation and management of biliary tract complications after orthotopic liver transplantation (OLT) have been previously demonstrated. However, the role of ERCP in evaluating asymptomatic OLT patients with abnormal liver enzymes with a previously normal biliary tree remains poorly defined. We sought to assess the utility of ERCP in this subset of patients. METHODS: A retrospective analysis of-asymptomatic OLT patients with abnormal liver enzymes evaluated by ERCP was undertaken. In addition to ERCP, all these patients had a diagnostic abdominal Doppler ultrasound, and a percutaneous liver biopsy. All patients had choledochocholedochostomy at the time of transplant and normal T-tube cholangiograms 3 months postoperatively. A radiologist, blinded to clinical findings, interpreted the ultrasound as normal, biliary dilation, or vascular abnormalities. The same radiologist interpreted ERCP findings. A pathologist, blinded to clinical findings, graded liver biopsies as normal, diagnostic, or abnormal but nondiagnostic. RESULTS: Twenty-two patients underwent 23 ERCPs. Twenty-two of the 23 ERCPs were normal (96%), and one abnormal ERCP finding did not explain the liver enzyme abnormality. Liver biopsy was diagnostic in 13 of 22 (57%) and in each case the ERCP was normal. The remaining 10 liver biopsies were abnormal but nondiagnostic. Ultrasound was abnormal in five of 22 cases, but in the three cases suggesting biliary dilation, the ERCP was interpreted as normal. CONCLUSION: Routine use of ERCP in evaluation of asymptomatic OLT patients with liver function test abnormalities and normal cholangiograms at 3 months was not diagnostically useful. In this subset of patients, liver biopsy was usually abnormal and frequently diagnostic and should be the initial invasive diagnostic procedure.     

Prenatal diagnostic and prognostic value of human cytomegalovirus load and IgM antibody response in blood of congenitally infected fetuses

Human cytomegalovirus (HCMV) load and virus-specific IgM were quantified in blood of 36 fetuses from mothers with primary HCMV infection. Nineteen fetuses were congenitally infected and 17 were uninfected as diagnosed by virus isolation from and DNA detection in amniotic fluid. Sensitivity of antigenemia was 57.9%; of viremia, 55. 5%; of leukoDNAemia, 82.3%; and of IgM, 57.9%; specificity was 100% for all assays. When amniocentesis was performed, 4 HCMV-infected fetuses (group A) showed abnormal ultrasound and biochemical/hematologic findings, 8 (group B) had elevated gamma-glutamyl transferase values, and 7 (group C) had normal ultrasound and biochemical findings. Virus loads were higher in groups A and B than in group C. In group A, no pregnancy went to term, in group B, 3 of 6 newborns were symptomatic at birth, and in group C, the 6 newborns were subclinically infected. Taken together, virologic, laboratory, and ultrasound findings may contribute to a better prognostic definition of fetal HCMV infection.     

Detection of previous proximal venous thrombosis with Doppler ultrasonography and photoplethysmography

To evaluate the reliability of two noninvasive tests, the photoplethysmograph (PPG) and venous Doppler ultrasound, in determining the presence or absence of previous proximal deep vein thrombosis (DVT), we performed a blinded retrospective cohort study of patients with objectively confirmed (DVT+) or refuted (DVT-) previous episodes of suspected DVT. Twenty-nine of 33 DVT+ patients had abnormal PPG and/or reflux by venous Doppler ultrasound, whereas 39 of 49 DVT- patients had normal PPG and no Doppler reflux (sensitivity, 88%; specificity, 80%). Of 33 DVT+ patients, 20 had abnormal Doppler results (sensitivity, 61%), in contrast to 46 of 49 DVT- patients with normal results (specificity, 94%). Moreover, 23 of 33 DVT+ patients showed abnormal PPG results (sensitivity, 70%), whereas 40 of 49 DVT- patients had normal PPG (specificity, 82%). Based on our findings, the presence of Doppler reflux is specific for previous proximal DVT, whereas a combination of normal PPG and Doppler ultrasound is reliable for excluding previous proximal DVT. Abnormal PPG with normal Doppler ultrasound does not reliably predict the presence or absence of previous DVT. However, this occurred in only 16 of 82 patients. Therefore, the combination of PPG and venous Doppler ultrasound can reliably predict the presence or absence of previous proximal DVT in most patients.     

The expression of activin-betaA- and -betaB-subunits, follistatin, and activin type II receptors in fallopian tubes bearing an ectopic pregnancy

CONTEXT: Ectopic pregnancy is a major cause of maternal morbidity and mortality with increasing incidence worldwide. OBJECTIVE: We investigated whether epithelia from Fallopian tubes (FTs) bearing an ectopic pregnancy differ from normal tubes in expression of TGF-beta family and related proteins and their receptors. METHODOLOGY: Because it is not possible to collect FTs from women carrying a healthy pregnancy, we studied tissue collected at the time of hysterectomy for benign disease. Women were injected with human chorionic gonadotropin in the days leading up to hysterectomy to produce a state of pseudopregnancy. Pseudopregnancy status was confirmed by the presence of high serum progesterone levels and the decidualization of the endometrium. Fifteen FTs bearing ectopic pregnancy and six pseudopregnant tubes were collected and examined using immunohistochemistry and quantitative RT-PCR. RESULTS: Immunohistochemistry demonstrated clear staining for the betaA- and betaB-subunits, type II receptor group comprising the activin type IIA and type IIB receptors, and follistatin, which increased in intensity from the isthmus to the ampulla in both models. However, the intensity of expression of these molecules was stronger in the ectopic pregnancy group when compared with the pseudopregnant group. Quantitative RT-PCR showed significant decrease in mRNA levels of betaA-subunit, activin type IIA and IIB receptors, and follistatin in ectopic group (P < 0.05) but no changes in betaB-subunit (P > 0.05). Overall, there was an apparent paradox of high concentration of protein but low mRNA expression. CONCLUSION: Activin-A may stimulate tubal decidualization and trophoblast invasion. A better understanding of the mechanism by which an embryo implants in the tubal epithelium may lead to improved methods for early diagnosis and/or management of ectopic pregnancy.     

Clinical use of placental hormones in pregnancy management

Across human pregnancy, placenta represents a transit of oxygen and nutrients from the mother to the fetus and actively produces a large number of hormones that serve to regulate and balance maternal and fetal physiology. An abnormal secretion of placental hormones may be part of the pathogenesis of the main obstetric syndrome, from early to late pregnancy, in particular chromosomopathies, miscarriage, gestational trophoblastic diseases, preeclampsia, gestational diabetes, and pre-term delivery. The possibility to measure placental hormones represents an important tool not only for the diagnosis and management of gestational disorders, but it is also fundamental in the early identification of women at risk for these pregnancy complications. In the last decades, the use of ultrasound examination has provided additional biophysical markers, improving the early diagnosis of gestational diseases. In conclusion, while few placental hormones have sufficient sensitivity for clinical application, there are promising new biochemical and biophysical markers that, if used in combination, may provide a valid screening tool.