Elevated antitoxin titers in a man with generalized tetanus

STUDY OBJECTIVE: To compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) after laparoscopic surgery in women with endometriosis with that of patients with tubal factor infertility. DESIGN: Retrospective survey of hospital and office charts using a computerized worksheet. SETTING: Lin-Kou medical center of Chang Gung Memorial Hospital. PATIENTS: Sixty-seven women with minimal to mild or moderate to severe endometriosis. Women with tubal factor infertility without other associated disorders (60 cycles) made up the control group. INTERVENTIONS: Seventy-five consecutive cycles of IVF-ET were performed in these patients who failed to conceive after laparoscopic conservative surgery. MEASUREMENTS AND MAIN RESULTS: The concentration of serum estradiol on the day of human chorionic gonadotropin (hCG) injection, the day of hCG injection, clinical pregnancy rates per transfer, number of follicles larger than 14 mm, number of embryos transferred, and implantation rate were not significantly different between women with endometriosis and those with tubal factor infertility. The number of oocytes retrieved and number fertilized were decreased, and the basal level of follicle-stimulating hormone on cycle day 3 was higher in women with both degrees of endometriosis. Women in both endometriosis groups received more follicle-stimulating hormone and human menopausal gonadotropin than those with tubal factor infertility. CONCLUSIONS: The outcome of IVF-ET in patients with endometriosis after laparoscopic surgery did not differ from that in the group with tubal factor infertility, but the former required more ampules of gonadotropin to achieve the same response. The advantages of laparoscopic surgery in women with endometriosis should be probably correlated with success of IVF-ET.     

Platelet transfusion practice: time for renewed consensus

BACKGROUND: Bilateral tubal pregnancies are rare and are usually confirmed simultaneously during the same operation. We report a case in which the right salpingectomy was performed seven weeks before the left salpingectomy. When the right salpingectomy was done, the left uterine tube appeared entirely normal. CASE: A 38-year-old woman underwent laparoscopic surgery for suspected right tubal pregnancy. A right tubal pregnancy was found to have partially aborted into the peritoneal cavity. The left uterine tube was carefully inspected and appeared normal. Histopathology of the right tube showed products of conception and chorionic tissue. Seven weeks after surgery, the woman presented in hemorrhagic shock necessitating emergency laparotomy and left salpingectomy. Histopathology of the left tube confirmed the presence of chronic tissue. The patient did not have coitus between the two salpingectomies. CONCLUSION: The explanation of the presentation is uncertain. However, this case underscores the importance of careful follow-up of patients after laparoscopic surgery for ectopic pregnancies.     

Randomized trial of conservative laparoscopic treatment and methotrexate administration in ectopic pregnancy and subsequent fertility

Methotrexate treatment was compared to laparoscopic salpingotomy for conservative management of ectopic pregnancy in a prospective randomized study. One hundred patients were randomized into two groups using random numbers. Inclusion criteria were an ectopic pregnancy visualized by ultrasound with a pre-therapeutic score <13 as assessed by the following six criteria, graded from 1 to 3: gestational age, human chorionic gonadotrophin (HCG) concentration, progesterone concentration, abdominal pain, haemoperitoneal volume and diameter of the haematosalpinx. The treatments were either 1 mg/kg of methotrexate injected transvaginally into the ectopic pregnancy without anaesthesia or administered i.m. when the pregnancy could not safely or easily be punctured (group 1), or laparoscopic salpingotomy (group 2). Success was defined as the return to normal (<10 mIU/ml) of HCG concentrations. Treatment was successful for 45 of 51 patients in group 1 (88.2%) and 47 of 49 in group 2 (95.9%). Medical treatment was significantly (P < 0.05) associated with shorter postoperative stay (24 compared with 46 h), but HCG returned to normal more quickly after laparoscopic treatment (13 compared with 29 days). Spontaneous reproductive performance was similar in both groups, but overall intrauterine pregnancy was higher, and repeat ectopic pregnancy lower, after methotrexate treatment. In selected cases of ectopic pregnancy, with a pre-therapeutic score <13, methotrexate treatment appeared as safe and efficient as conservative treatment by laparoscopy and was associated with improved subsequent fertility.     

Early warning of new health care technologies in the United Kingdom

OBJECTIVE: To evaluate fertility after salpingectomy performed for ectopic pregnancies (EPs). DESIGN: Retrospective cohort study. SETTING: Tertiary care university hospital. PATIENT(S): Three hundred forty patients (213 with surgery by laparoscopy and 127 by laparotomy) between January 1985 and July 1994, with a mean follow-up period of 73 months (36-162 months). INTERVENTION(S): Salpingectomy performed either by laparotomy or by laparoscopy as indicated. MAIN OUTCOME MEASURE(S): Rate of intrauterine pregnancy (IUP), live births, and recurrent EP. RESULT(S): Forty-seven (13.8%) patients were lost to follow-up, and 68 (20%) did not want to become pregnant. The overall rate of spontaneous conception was 70.4% in the laparoscopy group and 53.2% in the laparotomy group. The rate of live births was 50% and 37%, respectively; the mean time until conception was 11 and 17.2 months; and the rate of recurrent EP, 10.6% and 9.6%. The multivariate analysis showed a rate of IUP of 82.1% among women younger than 30 years of age with a normal contralateral tube, laparoscopic surgery, and no history of infertility. CONCLUSIONS: In this study of fertility after salpingectomy for EP, laparoscopic treatment was superior to laparotomic treatment. Fertility was equivalent to that after conservative treatment in a subgroup of young patients treated with laparoscopy and with no history of tubal pathology.     

Utility of the radial-deviated, thumb-abducted lateral radiographic view for the diagnosis of hamate hook fractures: case report

Data from all 225 women operated on for ectopic pregnancy in 1992-1994 at Sahlgrenska University Hospital were collected and compared with three previous cross-sectional investigations from our hospital (1975-1979, 1981-1982 and 1986-1987) in order to evaluate the extent to which surgical treatment and post-operative complications have changed over a 20 year period. Laparoscopic surgery, which was not possible in the 1970s, was used in almost 85% of the ectopic pregnancies in 1992-1994. Conservative treatment was still the most frequently used technique. The complication rate was 1.2% in 1975-1979 when only laparotomies were carried out. After the introduction of laparoscopic surgery (1986-1987), the complication rate rose significantly (7.3%) and continued to increase even when this procedure was established as routine (14.2% in 1992-1994). Post-operative complications were most frequent after conservative laparoscopic surgery (24.4%) while there were no complications after laparotomies. In spite of increasing complication rates the frequency of patients in pre-shock, as well as the proportion of patients with heavy intra-abdominal bleeding and tubal rupture, decreased over time.     

Trans-signaling by cytokine and growth factor receptors

OBJECTIVE: to compare methotrexate (MTX) to laparoscopic salpingotomy for conservative management of ectopic pregnancy (EP). DESIGN: prospective randomized study. PATIENTS: eighty-nine patients were randomized into 2 groups using a random number table. Inclusion criteria were an EP visualized by ultrasound with a pretherapeutic score < or = 13 as assessed by 6 criteria graded from 1 to 3: gestational age, hCG level, P level, abdominal pain, volume of the hemoperitoneum, and diameter of the hematosalpinx. INTERVENTIONS: 1 mg/kg of MTX injected transvaginally into the ectopic pregnancy without anaesthesia or IM administration (1.5 mg/kg) when EP cannot be safely or easily punctured (group 1) versus laparoscopic salpingotomy (group 2). RESULTS: the success rates defined by hCG levels returned to normal (< 10 mlU/mL) were 43 out of 46 in group 1 and 40 out of 43 in group 2. Medical treatment was significantly associated with shorter post-operative stay (24 vs 46 hours). hCG return to normal was quicker after laparoscopic treatment (13 vs 29 days). Reproductive performances were similar in both groups. CONCLUSIONS: in selected cases of EP with a pretherapeutic score < or = 13, MTX treatment appeared to be as safe and efficient as was conservative treatment by laparoscopy, an expectant management should be offered as a treatment option only in women fulfilling the criteria for a good prognostic.     

Injection of 5-fluorouracil in the treatment of tubal pregnancy through salpingo-catheter under hysteroscopy

Seventeen women with unruptured tubal pregnancy were given 5-FU through salpingo-catheter under hysteroscopy. In one case the injection failed because the tube opening could not be found. The success rate of salpingo-catheterization was 94.12% (16/17). The cure rate for the tubal pregnancies was 88.24% (15/17). 12 cases received injection once and 3 cases twice. The dose of 5-FU per injection was 250 mg in 10 ml solution. Serum beta-hCG test became negative in 7 to 14 days after the treatment, and signs and symptoms disappeared. Salpingography were done in 8 cases after 2 to 3 months, and all the diseased tubes were found patient. There was little side effects due to this treatment, which is more effective, convenient and less traumatic than injecting 5-FU to the affected site through laparoscopy or systemic administration. It may turn out to be an effective, simple, safe and acceptable new method for treating early tubal pregnancy.     

Radiographic evaluation of the renal vasculature

The two main conservative treatment alternatives for tubal pregnancy, methotrexate administration and laparoscopic salpingostomy are under constant review. Recently, expectant management of tubal pregnancy has become increasingly popular. In this review, we assess the outcome of conservative management modalities for extrauterine pregnancy and compare the results of treatment with methotrexate and operative laparoscopy. Outcomes of extrauterine pregnancy were obtained from a review compiled from the English literature identified by directed Medline search. Methotrexate and laparoscopic salpingostomies yield good final treatment rates of 85-95% respectively and relatively low rates for further surgical complication (5-10% respectively). Tubal patency, as well as future fertility performance, are quite similar after both techniques. Although they appear to suit the demands of the 21st century, each one has its own benefits and contraindications. With adequate patient selection, expectant management of the tubal pregnancy is a reasonable approach with good results. Although the morbidity rate after tubal pregnancy treatment is decreasing and the main concern is to reduce the decline in fertility potential, the real future challenge remains prevention of the disease, especially among high risk patients, such as those undergoing infertility treatment.     

Fertility after conservative and radical surgery for tubal pregnancy

A retrospective cohort study was set up to evaluate the effectiveness of conservative and radical surgery for tubal pregnancy towards subsequent fertility. Consecutive patients undergoing conservative or radical surgery for tubal pregnancy between January 1990 and August 1993 in two university hospitals were included in the study. Outcome measures were spontaneous intrauterine pregnancy (IUP) and repeat ectopic pregnancy (EP). Of the 135 patients analysed, 56 underwent conservative surgery and 79 underwent radical surgery. Patients treated with conservative surgery achieved a higher 3-year cumulative pregnancy rate than those treated radically (P < 0.001, log-rank test). In patients treated conservatively, there was only one spontaneous IUP in the period between 18 months and 3 years after the tubal pregnancy. In contrast, patients treated radically continued to conceive in this period. Multivariate analysis showed a fecundity rate ratio (FRR) of 1.9 [95% confidence interval (CI): 0.91 to 3.8] for IUP after conservative surgery in the first 18 months of follow-up. In patients with a history of bilateral tubal disease the FRR was 3.1 (95% CI: 0.76 to 12), whereas in patients without a history of bilateral tubal disease the FRR was 1.4 (95% CI: 0.13 to 16). The FRR for repeat EP was 2.4 (95% CI: 0.57 to 11). Our data indicate a beneficial effect of conservative surgery towards subsequent fertility that was not, however, statistically significant in the multivariate analysis. In view of these inconclusive data and the importance of this major health problem, randomized studies are required to assess whether conservative surgery really improves the fertility prospects of patients with tubal pregnancy.     

Placental isoferritin patterns during normal first trimester and tubal gestations

Placental isoferritin (PLF) has been shown to be involved in the down-regulation of the maternal immune system during pregnancy. In a prospective study, serum PLF concentrations were measured in 33 pregnant women with singleton, normal, ongoing first trimester gestations and compared with those of 22 women with tubal gestations. Diagnoses were based on endocrinological, sonographic, intra-operative and histopathological criteria. Venous blood was obtained from both groups for PLF determination before evacuation of the pregnancy products. beta-Human chorionic gonadotrophin (HCG), 17 beta-oestradiol and progesterone were determined at surgery for the tubal pregnancy patients. The mean +/- SD PLF concentrations were 18 +/- 14, 25.4 +/- 42.3 IU/ml among normal and tubal gestations respectively. Significant differences between normal and tubal pregnancies were found (P < 0.05). Based on PLF measurements, sensitivity (67%) and specificity (33%) values were found to be similar for the normal and ectopic pregnancies. No correlation was found between the other measured pregnancy hormones and PLF for the tubal pregnancy group. Low PLF concentrations among pathological gestations may reflect abnormal trophoblastic activity. The simultaneous assessment of PLF and beta-HCG concentrations which probably originate from different trophoblastic cells, is recommended for better diagnosis and monitoring of first trimester placental activity.     

The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group

BACKGROUND: Tubal sterilization is an increasingly common method of contraception in the United States. Although pregnancy after sterilization is uncommon, it can occur and may be ectopic. We used data from the U.S. Collaborative Review of Sterilization to estimate the risk of ectopic pregnancy in women who had undergone the common types of tubal sterilization. METHODS: A total of 10,685 women undergoing tubal sterilization were followed in a multicenter, prospective cohort study. We intended to follow all the women for 5 years by means of annual telephone interviews; for women enrolled early in the study, we attempted an additional follow-up telephone interview 8 to 14 years after sterilization. To assess the risk of ectopic pregnancy in these women, we used cumulative life-table probabilities and proportional-hazards analysis. RESULTS: There were 47 ectopic pregnancies in the 10,685 women; the 10-year cumulative probability of ectopic pregnancy for all methods of tubal sterilization combined was 7.3 per 1000 procedures. The cumulative probability varied substantially according to the method of sterilization and the woman's age at the time of sterilization. Women sterilized by bipolar tubal coagulation before the age of 30 years had a probability of ectopic pregnancy that was 27 times as high as that among women of similar age who underwent postpartum partial salpingectomy (31.9 vs. 1.2 ectopic pregnancies per 1000 procedures). The annual rate of ectopic pregnancy for all methods combined in the 4th through 10th years after sterilization was no lower than that in the first 3 years. CONCLUSIONS: A history of tubal sterilization does not rule out the possibility of ectopic pregnancy, even many years after the procedure.     

Developmental differences in catalase activity and hypoxic-hyperoxic effects on fluid balance in isolated lamb lungs

From these data, it seems highly likely that conservation of the involved tube does not substantially increase the risk of a future ectopic pregnancy, although it does slightly increase the chance of a subsequent intrauterine pregnancy. This advantage of conservative therapy is also demonstrable in patients with a repeat tubal pregnancy. Pregnancy rates after conservative operation still compare favorably with those after in vitro fertilization. There seems to be a slightly increased risk of persistent trophoblastic activity after laparoscopic conservative therapy compared with conservative surgical treatment by laparotomy, but prospective randomized data are lacking. The psychosocial and economic benefits of laparoscopic treatment are well established.     

Cornual pregnancies in patients with prior salpingectomy undergoing in vitro fertilization and embryo transfer

OBJECTIVE: To examine the frequency of cornual pregnancy in patients with prior salpingectomy undergoing IVF. DESIGN: Review. SETTING: Private fertility practice. PATIENTS: Women undergoing IVF. MAIN OUTCOME MEASURE: Cornual ectopic pregnancy. RESULTS: Of 26 ectopic pregnancies detected after ET during a 7-year period, 7 were located in the cornu or tubal stump after prior salpingectomy. CONCLUSIONS: Patients with prior salpingectomy undergoing IVF are at particular risk for cornual pregnancy.     

Evaluating the role of incidental diagnostic dilation and curettage in young women undergoing elective laparoscopic sterilization

Two hundred twenty-two women undergoing incidental diagnostic dilation and curettage (D&C) at the time of elective laparoscopic tubal ligation were studied retrospectively to ascertain if the risks of a D&C were warranted in a group of young, healthy women with a low risk of endometrial pathology. The endometrial sampling was associated with five uterine perforations and one readmission for bleeding and did not uncover any significant pathology in women under 35. The endocervical curettings did yield pathology of some clinical significance in women of all ages. The risk of uterine perforation was significantly higher in women who were < 15 weeks postpartum. We conclude that in a population of asymptomatic women under the age of 35, a diagnostic D&C is not indicated at the time of elective laparoscopic tubal ligation.     

Combined intra-uterine and extra-uterine pregnancy associated with mild hyperstimulation syndrome after clomiphene ovulation induction

We report a combined intra-uterine and tubal pregnancy associated with mild ovarian hyperstimulation syndrome (OHSS) following ovulation induction by clomiphene. The diagnosis of ectopic pregnancy was originally missed until rupture occurred. OHSS confused the clinical picture, the important diagnostic feature being the fall in the haemoglobin concentration. The patient had a left partial salpingectomy and the uterine pregnancy progresses normally.     

Paget disease of the calcaneus: findings on MR imaging

The aim of the current study was to examine whether the measurement of intrauterine human decidua-associated protein (hDP) 200 might be of clinical value in the diagnosis of ectopic pregnancy versus early missed abortion. Uterine fluid levels of hDP 200 were measured in two groups of patients: 20 women with ectopic pregnancy, diagnosed by laparoscopy, and 20 women diagnosed (after curettage) as having a missed abortion. No significant difference in hDP 200 levels was observed comparing patients with ectopic pregnancy (mean 114.0+/-58.2 mU/ml) and patients with early missed abortion (mean 222.0+/-116.0 mU/ml), although a trend towards lower levels of uterine fluid hDP 200 was noted in the group of patients presenting with tubal pregnancy. Thus, according to our data, intrauterine hDP 200 is not sufficiently discriminative to be of clinical value in the diagnosis of ectopic pregnancy.     

Chlamydial genital infections and laparoscopic findings in infertile women

Several studies have shown that previous chlamydial genital infection, reflected by serological markers, is strongly associated with tubal damage leading to tubal infertility. In 105 women undergoing laparoscopy, multiple samples were collected from the lower (urethra and cervix) and upper (endometrium, peritoneal fluid, tubal lumen) genital tract, in order to isolate Chlamydia trachomatis in cell culture. Chlamydia trachomatis was isolated from at least one site in 13 (30.9%) of 42 infertile women with tubal infertility, in 5 (12.1%) of 41 women with unexplained infertility, in 1 of 4 women affected by acute salpingitis and in 1 (5.5%) of 18 women with endometriosis or uterine malformations. The latter group was the control group. Thirteen (65%) of the 20 positive women harboured Chlamydia trachomatis in their upper genital tract alone and 16 women were positive in one or both tubes. Only one of the positive women showed laparoscopic signs of acute pelvic infection. Four of the 5 positive women with unexplained infertility harboured Chlamydia trachomatis in the tubal lumen. This study confirms that chlamydial infection is strongly associated with tubal damage. It suggests that cervical cultures are inadequate for excluding a tubal infection and that chlamydial colonization of the tubal mucosa is possible in the absence of symptoms and laparoscopic signs of active infection.     

Erythrocyte Na/K ATPase activity and diabetes: relationship with C-peptide level

The purpose of this study is to clarify the volume effect of epidural saline injection 20 min after spinal anesthesia. Thirty patients undergoing combined spinal and epidural anesthesia for orthopedic surgery were randomly divided into two groups: a control group (n = 15) and a saline group (n = 15). In the control group, 2% lidocaine 3 ml with 0.4% tetracaine was injected into the subarachnoid space from L 4-5 interspace using Durasafe (Becton Dickinson, USA) and saline was not injected into the epidural space. In the saline group, saline 10 ml was injected through an epidural catheter 20 min after spinal anesthesia. The levels of analgesia 20 min after spinal anesthesia were not significantly different between the groups. However, the levels of analgesia 3, 5, 10, 40 and 100 min after epidural saline injection in the saline group were significantly higher than those in the control group (P < 0.05). The highest analgesic level was obtained 10 min after epidural saline injection and reached to T 4.3 +/- 1.1. In conclusion, epidural saline injection increases the analgesic level 20 min after spinal anesthesia because of the volume effect.     

Methylene blue dyeing of cellular nuclei during salpingoscopy, a new in-vivo method to evaluate vitality of tubal epithelium

The Fallopian tube can be damaged by different noxious substances that may change cellular ultrastructure and function. Alteration of the cell membrane allows the passage of certain aniline dyes, which can stain the nucleus. A total of 310 Fallopian tubes from 163 patients who underwent a surgical or diagnostic laparoscopy during fertility studies was analysed by salpingoscopy. Cellular nuclei were stained by injection of 20 ml of a 10% solution of methylene blue in saline solution (NaCl 10%) through the cervical cannula prior to salpingoscopy. Evaluation of nuclear staining with methylene blue, adhesions, vascular alterations, and the flattening of folds in relation to pregnancy outcome was undertaken. Quantification of salpingoscopic findings was carried out according to a score. Flattening of folds and vascular alterations showed no difference in the pregnant and non-pregnant groups. On the other hand, adhesions and nuclear dyeing were significantly greater in the non-pregnant group (adhesions 13.6 versus 26.8%, P < 0.004, and nuclear dyeing: 25 versus 41.7%, P < 0.009, pregnant versus non-pregnant). Methylene blue dye is a new tool to evaluate in vivo cyto-histological tubal damage, and is a useful and simple method to provide a prognosis of salpingean function.     

Blockade of morphine-induced place preference by diazepam in mice

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.