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     

Time trends in ectopic pregnancies in a Norwegian county 1970-2004--a population-based study

BACKGROUND: The study objective was to estimate temporal trends in ectopic pregnancy in a well-defined population. METHODS: We identified patients with ectopic pregnancy in hospital discharge registries in S?r-Tr?ndelag County, Norway, 1970-2004, and retrieved data from medical records. We calculated age-specific ectopic pregnancy incidence, proportions of patients with first ectopic pregnancy/prior infertility treatment, incidence of ectopic pregnancy by birth cohort and age and ratio of ectopic pregnancy to live births (extrauterine ratio) by age and parity. RESULTS: Age-adjusted ectopic pregnancy incidence rates increased from 4.3 to 16.0 per 10 000 women-years over the period 1970-1974 to 1990-1994 and declined to 8.4 per 10 000 women-years in 2000-2004. Incidences were highest among women aged 25-34 years throughout the study period. We observed decreases in proportions of women with previous ectopic pregnancy and with prior infertility treatment after 1990-1994. Incidence rates were the highest for women born between 1960 and 1964 in all age groups. Extrauterine ratio increased with age and was higher for women with two or more previous births compared with women with none or one prior birth. CONCLUSIONS: The epidemic increase in ectopic pregnancy towards 1990-1994 was followed by a marked decrease.     

Simultaneous intrauterine and ectopic pregnancies following in-vitro fertilization and gamete intra-fallopian transfer. A review of nine cases

This paper reports nine cases of simultaneous intrauterine and ectopic pregnancies which followed in-vitro fertilization (three cases) and gamete intra-Fallopian transfer (six cases). The ectopic pregnancies were treated by aspiration and injection of potassium chloride and methotrexate (five cases), salpingectomy (three cases) or laparoscopic evacuation (one case). In five of the nine patients the intrauterine pregnancies continued until after the 35th week and the patients delivered live infants. The role of vaginal ultrasound scanning in making the diagnosis was emphasized. The literature on heterotropic pregnancy is reviewed.     

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.     

Laparoscopic management of an ectopic pregnancy in a previous Caesarean section scar.

A case of laparoscopic management of an ectopic pregnancy in a previous Caesarean section scar is reported. A 30 year old woman was admitted to our hospital for profuse vaginal bleeding 2 weeks after an abortion had been performed. A urine pregnancy test was positive. Abdominal ultrasound revealed a well-encapsulated bulging mass over the lower anterior uterine wall measuring 7x5 cm. Hysteroscopy revealed retained gestational tissue in the lower corpus despite a normal uterine cavity. An incision was made over the most prominent area of the mass by operative laparoscopy. Dark reddish tissue suggestive of the products of conception was removed using grasping forceps. One-layer of continuous endoscopic sutures along the affected uterine wall was made with 1-0 Prolene. Laparoscopy enabled the successful treatment of an unruptured ectopic pregnancy in a previous Caesarean scar and made it possible to preserve the patient's reproductive capability.     

Pregnancy: A comparison of methotrexate versus laparoscopic surgery for the treatment of ectopic pregnancy: a cost analysis

This study was a cost analysis of direct medical costs of themethotrexate management versus laparoscopic surgery in the treatmentof ectopic pregnancy. A total of 40 patients treated from January1991 to October 1994 with methotrexate were compared with another40 patients treated at the same hospital by laparoscopy fromApril 1986 to June 1994. Medical records for all these patientswere received and hospital databases were used to retrieve informationon cost Treatment cost included the primary treatment, hospitalizationand outpatient follow-up necessitated by treatment, complicationsand secondary treatment in cases of treatment failure. The costrelated to diagnosis was excluded. The direct medical costsfor methotrexate and laparoscopy groups were based on successrates of 72.5 and 95% respectively. The total cost of methotrexatetreatment was Canadian $35 180 compared with Canadian $73 440for the laparoscopic treatment. The mean ± SE cost perpatient was Canadian $880 ± 160 in the methotrexate groupcompared with Canadian $1840 ± 150 in the laparoscopicgroup (P 0.001). The mean ± SE cost per patient withmethotrexate success was Canadian $330 ± 67 comparedwith Canadian $2330 ± 220 per patient with methotrexatefailure (P = 0.001). A complete assessment of methotrexate treatment,including cost-benefit and cost-effectiveness, is warranted.     

Evaluation of the sites of ectopic pregnancies subsequent to reconstructive tubal surgery

The sites of ectopic pregnancies in women who underwent varioustypes of reconstructive tubal surgery were analysed and comparedto the controls. Overall, ectopic pregnancies subsequent toall types of tubal surgeries were more often implanted proximallycompared to the control population.     

The dilemma of the optimal surgical procedure in ectopic pregnancies occurring in in-vitro fertilization.

Ectopic pregnancy remains one of the undesired sequelae of in-vitro fertilization (IVF) treatment. It seems that mechanical infertility increases the risk of this complication in IVF. Thus, the surgeon treating such a case faces the dilemma of the optimal surgical procedure because of the increased risk for repeated ectopic pregnancy in subsequent IVF cycles. Two cases are presented with repeated ectopic pregnancy occurring in IVF. One case underwent salpingectomy on the first occasion and eventually developed a contralateral repeat ectopic gestation ending with salpingectomy. The second case underwent a conservative salpingotomy in the first event and developed a repeated ectopic gestation on the same side, undergoing bilateral salpingectomy. In order to prevent repeated ectopic pregnancies in an IVF programme, a definitive surgical procedure, such as bilateral salpingectomy, should be considered in the first episode in patients referred for IVF because of tubal pathology.     

Ectopic pregnancy is again on the increase. Recent trends in the incidence of ectopic pregnancies in France (1992-2002)

BACKGROUND: We aimed to assess the recent incidence trends of ectopic pregnancies (EP) in France (1992-2002). METHODS: A population-based register of all women aged 15-44 years with EP was set up in Auvergne (central France). We calculated rates of EP as a 'reproductive failure' or as a 'contraceptive failure', frequencies of exposure to the two main risk factors for EP (cigarette smoking and chlamydial infection) and contraceptive methods between 1992 and 2002. RESULTS: The overall EP rate decreased by 2%, from 96.4 per 100 000 women aged 15-44 in 1992 to 95.3 per 100 000 in 2002. However, the rate of 'reproductive failure' EP increased by 17%, while the rate of 'contraceptive failure' EP, mostly intrauterine device failure, decreased by 29%. CONCLUSION: Appropriate analysis reveals that the rate of EP as reproductive failure is increasing again in France. This result is of interest for many European and North America countries where chlamydial infections or smoking or both are increasing in women of reproductive age. The rates of EP as contraceptive failure and of that as reproductive failure evolve differently in the population and should not be confused in epidemiological studies.     

Declining incidence of ectopic pregnancy in a UK city health district between 1990 and 1999

BACKGROUND: On the basis of clinical impression that the number of cases of ectopic pregnancy seen in the City and Hackney Health District, London, was changing, a retrospective study of the years between 1990 and 1999 was carried out. METHODS: From the histopathology databases, cases of ectopic pregnancy and early pregnancy failure were identified. The number of deliveries at The Homerton Hospital was obtained from the Labour Ward register; the number of terminations of pregnancy and the number of fertile women was obtained from the Office for National Statistics, UK. RESULTS: There were 73 cases of ectopic pregnancy in 1990 rising to 96 in 1991 and then a fall to 52 cases in 1999. In terms of ectopic pregnancy per 100 deliveries, per all known pregnancies and per 1000 fertile women per year, there was a peak in 1991 and a fall to 1999. With regard to relative incidence per deliveries and per all known pregnancies, these falls were significant (P < 0.05). In 1991, there were 2.4 ectopic pregnancies per 100 deliveries, falling to 1.6 in 1999, a 33% fall. The reasons for this large decline are uncertain. CONCLUSIONS: There has been no change in patient population, diagnostic aids used or management protocols for patients with ectopic pregnancies.     

Leukocyte populations, hormone receptors and apoptosis in eutopic and ectopic first trimester human pregnancies

The implantation of trophoblast cells at extrauterine sites still results in decidualization. The objective of the present study was to compare decidualization at eutopic and ectopic implantation sites. Tissues from women undergoing elective termination of uterine pregnancy and from women with ectopic pregnancy were used to detect the presence of cells important for the maintenance of pregnancy, such as BCL-2+, CD56+, CD3+, CD8+ and CD68+ cells, and the presence of oestrogen (ER) and progesterone receptors (PR) by immunohistochemistry. In-situ detection of fragmented DNA was performed to identify apoptotic cells. The percentage of CD3+ cells among all immunocompetent cells in the tubal epithelium was 46.6% (39.9% of CD3+ were also CD8+); the other 53.4% were CD68+ cells. CD56+ cells were undetectable in ectopic decidua at the feto-maternal interface in ectopic tissue. In uterine decidua, we found 29.9% CD3+ cells (2.2% of CD3+ were CD8+), 51.6% CD56+ cells and 18.5% CD68+ cells. The ratio of BCL2+ to CD3+ cells in ectopic pregnancy was 0.41. In uterine pregnancy, the ratio of BCL-2 to CD3 was 0.44 and 0.39 for CD56. Tissues from both ectopic and uterine pregnancies were positive for PR. Fewer apoptotic cell bodies were present in ectopic pregnancy. The use of tissue obtained from ectopic pregnancy may become an excellent model to identify the mechanism of trophoblast invasion in eutopic pregnancies.     

Distinction between early normal intrauterine pregnancies and pathological pregnancies by means of a logistic model.

The probability of an unclear very early pregnancy being a normal intrauterine pregnancy was estimated using a logistic model. Five diagnostic measures of prognostic value were identified in the model: (i) daily change in human chorionic gonadotrophin (HCG), (ii) results of transvaginal ultrasound, (iii) vaginal bleeding, (iv) serum progesterone level and (v) risk score for ectopic pregnancy. With the use of this model, the probability of a normal intrauterine pregnancy has been estimated as 96.7%.     

Medical treatment of ectopic pregnancies: a randomized clinical trial comparing methotrexate-mifepristone and methotrexate-placebo

BACKGROUND: Medical treatment of ectopic pregnancies is common. To increase the efficacy of methotrexate, the association of mifepristone has been proposed. METHODS: We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo. RESULTS: A total of 212 ectopic pregnancies was randomized. There was no significant difference in the initial characteristics between the two groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n = 113) and the methotrexate-placebo group (n = 99): 79.6% (90/113) versus 74.2% (72/97) respectively, RR (95% CI): 1.07 (0.92-1.25), P = 0.41, non-significant. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was >/=10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with an 83.3% success rate (15/18) versus 38.5% (5/13) respectively. CONCLUSIONS: Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and baseline serum progesterone suggested that this combination could be limited to ectopic pregnancies associated with high serum progesterone concentrations.     

Incidence of ectopic pregnancy. First results of a population-based register in France

A population-based register of ectopic pregnancy was establishedin 1992 for two French departments, with the primary aim ofmonitoring the trend in ectopic pregnancy over a prolonged period.In this paper, data collected pregnancy over a prolonged period.In this paper, data collected during the first year of registration(1992) are analysed. The rate of ectopic pregnancy was 20.2per 1000 live birth, 15.8 per 1000 reported pregnancies and9.5 per 10 000 women aged 15–44 years. The ectopic pregnancyrate per 1000 live births increased steeply after the age of30 years and especially after the age of 35 years, whereas ratesper 10 000 women of reproductive age steadily increased untilthe age of 35 years and decreased thereafter. The rates of ectopicpregnancy were lower in spring and summer than autumn and winter.These results are discussed and comparisions with similar studiesconducted in the USA and Scandinavia are attempted.     

Local injection of methotrexate dissolved in saline versus methotrexate suspensions for the conservative treatment of ectopic pregnancy

To compare the local injection of methotrexate (MTX) dissolvedin saline and MTX suspensions for the laparo-scopic treatmentof ectopic pregnancy in terms of success rate and postoperativetubal patency. A total of 26 patients with unruptured ectopicpregnancies were selected from among 60 women with ectopic pregnanciesadmitted to the Nagasaki University clinic. Of these patients,12 were treated with MTX dissolved in saline solution (solutiongroup) and 14 with MTX suspensions consisting of lipiodol (LPD)with phosphatidylcholine (PC) added as a dispersing stabilizer(suspension group). Except for one case treated under transvaginalguidance, all the patients were treated by laparoscopy. Persistentectopic pregnancy was recognized in seven cases (58%) in thesolution group but in only two cases (14%) in the suspensiongroup. Moreover, rupture occurred in two cases in the solutiongroup but in no case in the suspension group. A patent treatedtube was found in seven of 10 cases in the saline group andin 10 of 12 cases in the suspension group. During the follow-upperiod of 6–31 months, five women in the saline groupand three women in the suspension group had an intrauterinepregnancy. In this study, the local injection of MTX is consideredto be a reasonable method for the treatment of unruptured ectopicpregnancy, and the MTX suspension seems to be more effectiveand useful than MTX solution.     

The use of a pretherapeutic, predictive score to determine inclusion criteria for the non-surgical treatment of ectopic pregnancy.

Non-surgical management of ectopic pregnancy has recently become an alternative to surgery. We have investigated a pretherapeutic score to define the indication for non-surgical and surgical treatment in 61 patients with ectopic pregnancy. The score was performed before the patients' inclusion in a nonsurgical management scheme. The score used six criteria which were evaluated on a scale from 1 to 3: gestational age, human chorionic gonadotrophin (HCG) level, progesterone level, abdominal pain, haemoperitoneum volume and haematosalpinx diameter (estimated by laparoscopy or transvaginal ultrasound). Three scores, 10, 11 and 12, were studied in order to define a threshold beyond which surgical treatment should be performed. For each one, sensitivity, specificity and positive and negative predictive values were analysed. The success rate of non-surgical treatment was 75% (46/61). For patients undergoing medical treatment with a score less than or equal to 12, the success rate was significantly higher compared with a success rate of 50% when the score was greater than 12. We conclude that a score less than or equal to 12 permits non-surgical management with a success rate of 82%. A score greater than 12 indicates that laparoscopic surgery may be more suitable. The choice between different non-surgical approaches, did not influence the success rate. When ultrasound reveals embryo heart activity, medical treatment is always possible if the score is less than or equal to 12.     

Spontaneous conception and intrauterine pregnancy in a symptomatic missed abortion of ectopic pregnancy conceived in the previous cycle

We encountered a rare case of combined intrauterine and extrauterinepregnancy that occurred following separate spontaneous ovulations.A 33 year old woman visited our hospital with the chief complaintof abdominal pain on April 16, 1993. Her last menstruation wasfrom March 23 for 6 days. However, the urinary human chorionicgonadotrophin (HCG) on April 19 was 1024 IU/L Pelvic examinationand ultrasonography indicated an extrauterine pregnancy, whichwas confirmed by laparotomy and histo-logical identificationof trophoblast cells. The urinary HCG concentration markedlydecreased after the operation. However, the HCG level increasedagain on the fifth postoperative day, and a gestational sac(11 mm) was identified in the uterine cavity on the 11th post-operativeday, indicating that this intrauterine pregnancy was establishedfollowing spontaneous ovulation which occurred before the removalof the extrauterine pregnancy. This case indicates that a combinedpregnancy can occur not only after simultaneous multiple ovulationsbut also after the separate spontaneous ovulations.     

Early outcome of myomectomy by laparotomy, minilaparotomy and laparoscopically assisted minilaparotomy. A randomized prospective study

BACKGROUND: To compare in the first 7 days after surgery the outcome of myomectomy performed by three laparotomic approaches: laparotomy (LT), minilaparotomy (MLT) and laparoscopically assisted minilaparotomy (LA-MLT). METHODS: Fifty-one women with 5-15 cm total myoma diameter were randomized blindly using a computer randomization list, to LT (n = 17), MLT (n = 17) or LA-MLT (n = 17). RESULTS: Mean operation length was similar in the three groups. Mean (+/- SEM) time of paralytic ileus (55.0 +/- 4.5 versus 33.4 +/- 3.4 h; P < 0.01) and discharge (141.6 +/- 5.2 versus 81.5 +/- 8.2 h; P < 0.01) was longer in LT than LA-MLT or even MLT. In comparison with LA-MLT, LT induced a greater haemoglobin decline (-3.07 +/- 0.3 versus -1.8 +/- 0.15 mg/dl; P < 0.025), and a greater post-operative stress, as documented by increased prolactin (+15.1 +/- 3.8 versus +0.16 +/- 4.5 ng/ml; P < 0.03) and decreased insulin sensitivity (fasting glucose/insulin; -7.5 +/- 2.6 versus -0.7 +/- 2.1; P < 0.02). Seven days after surgery, abdominal pain (P < 0.05) was higher after LT (3.0 +/- 0.6) than MLT (0.5 +/- 0.2) and LA-MLT (0.9 +/- 0.4). CONCLUSIONS: In selected cases, myomectomy by LA-MLT offers some advantages versus LT and, to a smaller extent, MLT.     

Pregnancy: Laparoscopy: a dispensable tool in the diagnosis of ectopic pregnancy?

Laparoscopy is regarded as the final decisive diagnostic testin suspected ectopic pregnancy. The new non-invasive diagnosticmethods of transvaginal sonography and serum human chorionicgonadotrophin (HCG) monitoring now challenge this pivotal roleof laparoscopy. In this prospective study the diagnostic valueof an algorithm, combining transvaginal sonography with an HCGcut-off level between 1000 and 1500 IU/I (IRP) was tested in208 consecutive women at risk for ectopic pregnancy. Three diagnosticcategories are designated by the algorithm: intra-uterine pregnancy(n = 73), ectopic pregnancy (n = 89), and trophoblast in regression(n = 46). The latter category represents patients in whom nopregnancy could be located by transvaginal sonography, withan initial HCG concentration < 1500 IU/I, declining duringfollow-up. The algorithm has a sensitivity of 0.97, a specificityof 0.95, a likelihood ratio for a positive test of 19.4, anda likelihood ratio for a negative test of 0.03. The describeddiagnostic strategy thus proved extremely reliable in the safemanagement of patients at risk for ectopic pregnancy, and renderslaparoscopy obsolete.     

A validation of the most commonly used protocol to predict the success of single-dose methotrexate in the treatment of ectopic pregnancy

BACKGROUND: Currently, the likely success of single-dose methotrexate (MTX) (50 mg/m(2)) for the treatment of ectopic pregnancy is indicated by a >15% decrease in hCG from days 4-7 after administration. The aim of this study was to assess this protocol and to develop new rules that could be used to predict the outcome at an earlier stage. METHODS: Data were collected prospectively. Women receiving MTX for an ectopic pregnancy had serum hCG and progesterone levels checked on days 1, 3, 4, 5 and 7. Other factors including age, gestational age, previous obstetric history and ultrasound findings were recorded. The women were followed up until the outcome of medical management was known. Univariate analysis was performed to determine the benefit of the '15% day 4-7 rule', as well as to develop new rules, which potentially could be used to predict the likelihood of success before 7 days. Historical and ultrasound variables were also analysed to identify the significant variables associated with successful conservative management. RESULTS: The success rate of single-dose MTX was 68.1% (47/69). A second dose was required in 18.8% (13/69) of cases, and it was successful in 84.6% (11/13). The 15% day 4-7 rule correctly predicted the outcome in 90.3% of cases [sensitivity 93.0%, specificity 84.2%, positive predictive value (PPV) 93.0% and negative predictive value (NPV) 84.2%, Fisher exact test P-value < 0.0001]. New rules were developed based on the percentage change day 4-5 and logistic regression models incorporating day 5 hCG levels and ultrasound findings. These new rules did not outperform the current 15% day 4-7 rule. CONCLUSIONS: We have confirmed that a 15% decrease in serum hCG between day 4 and day 7 is a very good indicator of the likely success of MTX. The development of new rules did not significantly improve our ability to predict a successful outcome at an earlier stage.