Conservative management of extra-uterine pregnancy

Expectant management was studied in 35 patients representing 4.9% of all ectopic pregnancies during an 8 year period. Laparoscopy was performed in a first period to define the inclusion criteria: hematosalpinx < or = 2 cm and hemoperitoneum < or = 50 ml. In a second period, inclusion criteria used a predictive pretherapeutic score < or = 11 with a sonographic visualization of the ectopic pregnancy. This score involved six criteria graded on a scale from 1 to 3: gestational age, hCG and P level, existence of abdominal pain, size of hemoperitoneum and diameter of hematosalpinx assessed sonographically. The patients were on out-patients basis. Success rate was 85.7% (30/35 patients). When the pretherapeutic score was < or = 11 and the initial hCG level < 1,000 mUl/ml the success rate increased to 96%. Thirteen patients (87%) had patent tubes evaluated by hysterosalpingography on the side of the ectopic pregnancy. Twelve patients delivered one miscarriage occurred and none ectopic pregnancy was observed. Expectant management is a useful form of treatment for ectopic pregnancy in selected cases.     

Survival of patients on chronic hemodialysis: single center experience

BACKGROUND: Cervical pregnancy is a rare form of ectopic pregnancy. This condition is usually treated with hysterectomy. CASE: A woman with an 11.3-week cervical pregnancy was treated with methotrexate, angiographic embolization of the anterior division of the hypogastric artery, dilatation and curettage, and minimal rollerball ablation of bleeding cervical vessels only. The patient was discharged on postoperative day 1. Complications included a malodorous discharge, which was treated with oral antibiotics, and claudication of the thighs for two weeks. CONCLUSION: Advanced cervical pregnancies can be treated conservatively.     

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.     

Medical management of interstitial ectopic pregnancy: a case report and literature review

Recent reports describe successful treatment of interstitial ectopic pregnancies using methotrexate. While the number of reported cases is increasing, no consensus exists regarding the management of this complication of pregnancy. We present the successful use of combined systemic and direct intrasac injection of methotrexate for an interstitial pregnancy with the highest yet reported initial beta-human chorionic gonadotrophin concentration (102,000 mIU/ml). We also describe the use of Doppler ultrasound for monitoring treatment progression. Through a review of the current literature, we propose to facilitate management decisions and increase outcome success by summarizing previously reported treatment regimens and by describing enhanced parameters for patient selection and monitoring.     

Mifepristone in combination with methotrexate for the medical treatment of tubal pregnancy: a randomized, controlled trial

In the search for a more potent alternative to a single i.m. injection of methotrexate for ectopic pregnancy, a randomized trial was organized. The efficacy of a combination of methotrexate and mifepristone was compared with methotrexate alone in the treatment of unruptured tubal pregnancies. The diagnosis of an unruptured tubal pregnancy was confirmed laparoscopically in 50 patients during a 2 year period. Women were randomized to receive a single i.m. injection of 50 mg/m2 methotrexate alone or a single dose of 600 mg oral mifepristone in combination with the same dose of methotrexate. Both treatment protocols were successful in achieving the resolution of unruptured ectopic pregnancy (18/25 in the methotrexate group and 22/25 in the combination group) following the initial intervention. A second injection was needed in four (16%) cases in the methotrexate group and in one (4%) case in the combination group. Overall, a complete resolution was achieved in 22/25 and 23/25 cases respectively. Unruptured ectopic pregnancy resolved faster in women given the combination of methotrexate and mifepristone compared to women given methotrexate only (P = 0.01). The effect of the methotrexate and mifepristone combination was more pronounced in women with higher human chorionic gonadotrophin concentrations.     

How to get the most from your iron supplement

BACKGROUND: Tubal effects of methotrexate injections have been poorly reported. CASES: Three fallopian tubes were examined with light microscopy 9-13 months after tubal methotrexate injection (one case) and intramuscular methotrexate injection (two cases) given for the treatment of unruptured ectopic pregnancies. No evidence of tubal damage was found. CONCLUSION: These three cases confirm previous experimental and clinical data showing the absence of a direct adverse effect of methotrexate on the fallopian tubes in the treatment of ectopic pregnancy.     

Ectopic bone formation in a child with a head injury: complete regression after immobilisation

OBJECTIVE: To study the correlation between microsurgical tubal reversal after tubal sterilization and ectopic pregnancy. METHODS: 1029 women who underwent microsurgical tubal reversal were followed up. The causes of ectopic pregnancy were analysed and discussed. RESULTS: 960 intrauterine pregnanciess and 12 ectopic pregnancies occurred. The 12 ectopic pregnancies were all tubal ones, among which 2 had intrauterine pregnancies. The rate of ectopic pregnancy in the 1029 women was 1.17%, and in the pregnant cases was 1.23%. The ratio of intrauterine pregnancy to ectopic pregnancy was 1:80. The rates of ectopic pregnancy in the 1st, 2nd year and 2 years later after tubal reversal were not significantly different respectively among the tubal reversal and among the pregnant cases. The rates of ectopic pregnancy in the 1st and 2nd 6 months after tubal reversal were not statistically different. The early tubal hydrapertubation could only increase the chance of ectopic pregnancy. The sterilization method, reversal mode, and interval between sterilization and reversal were not related to the ectopic pegnancy. CONCLUSION: When the lesion in the sterilized position is completely removed, the sutures being through the tubal mucosa and the early tubal hydrapertubation not carried out, the chance of ectopic pregnancy can not be increased after tubal reversal. The contraception 6 months after tubal reversal is not related to ectopic pregnancy.     

The role of scientific societies

Ectopic pregnancy is one of the most common and dangerous complications of the early pregnancy period. Until now diagnosis has been late because major symptoms occur after tubal rupture and so only demolitive surgery has been possible. At present, with the appearance of ultrasound in obstetrics an earlier diagnosis of this pathology can be made before tubal rupture so medical treatment has become possible. We treated a series of twelve patients with early ectopic pregnancy (9 tubal and 3 with no localized site of implantation) with intramuscular 0.5 mg/kg methotrexate and oral 0.1 mg/kg of folic acid (Citrovorum Factor) on alternate days, in the attempt to reduce hospitalization and obtain more effective and safer medical management. We observed a fall in serum beta-HCG levels after one cycle of treatment in 11 out of 12 patients and after two cycles of therapy in the remaining case. Minimal side-effects were observed in four cases. Three pregnancies occurred after treatment before the advised interval time and ended in blighted ovum. Methotrexate systemic therapy can be considered an elective treatment and a sufficiently safe management in early unruptured ectopic pregnancy when a good clinical selection of patients is performed.     

Methotrexate treatment of ectopic pregnancy. A pilot study

The incidence of ectopic pregnancy is rising but the clinical presentation of the disease has changed simultaneously. Nowadays, the majority of ectopic pregnancies are diagnosed before rupture. This stimulated us to attempt methotrexate therapy (1 mg/kg body weight injected locally or 50 mg given orally) in 12 cases verified by transvaginal ultrasound and presenting with increasing beta-hCG values. The treatment proved successful in 67% of the cases, even though high levels of beta-hCG and foetal heart activity were accepted as inclusion criteria. Eight patients later achieved intrauterine pregnancies, and seven healthy babies were delivered. Randomized, controlled studies are needed.     

The association between Chlamydia trachomatis serology and pelvic damage in women with tubal ectopic gestations

OBJECTIVE: To determine whether pelvic damage is associated with positive Chlamydia trachomatis serology in women with tubal ectopic pregnancy. DESIGN: Cross-sectional retrospective study. SETTING: A prepaid health maintenance organization. PATIENTS: Two-hundred eighty-one women admitted with confirmed tubal ectopic pregnancy were interviewed for history of sexually transmitted diseases. Chlamydia serology was obtained for 135 subjects, and operative findings were available for 121 of these. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Pelvic damage, as determined by review of operative findings of the pelvis at the time of ectopic surgery. RESULTS: Pelvic damage was associated with positive chlamydia serology with an adjusted odds ratio of 4.2 (95% confidence interval: 1.8 to 9.7). Moderate and severe pelvic damage were more strongly associated with positive serology than mild damage. CONCLUSIONS: Women with ectopic pregnancies and antibodies to C. trachomatis are more likely to have damaged pelves than women with ectopic pregnancies without such antibodies. Prevention or early treatment of C. trachomatis infection may reduce pelvic damage and, therefore, reduce incidence of ectopic pregnancy.     

Fertility after laparoscopic myomectomy: preliminary results

We report the limits, complications, subsequent fertility and outcome of pregnancies after laparoscopic myomectomy. From January 1990 to October 1995, 143 patients underwent a first laparoscopic approach to myomectomy. A total of 41 patients (28.7%) had a laparoconversion (12 cases for a number of myomata >5, 15 cases for myoma diameter >7 cm, 12 cases for peroperative haemorrhage and two cases for adenomyosis). Seventy patients (49%) wished to conceive: 26 had undergone laparoconversion and 44 laparoscopic myomectomy. A total of 19 pregnancies were obtained in 17 patients after laparoscopic myomectomy (38.6%): eight vaginal deliveries, three Caesarean sections, four miscarriages, two abortions, one ectopic pregnancy and one therapeutic abortion. The pregnancy rate in patients with unexplained infertility and with multifactorial infertility was 48.2% and 20% respectively. The mean delay to conception was 11.3 months. No uterine rupture was noted. Pelvic adhesions were found in the four patients who underwent second-look procedure. Our preliminary results indicate that laparoscopic myomectomy is a useful technique.     

Ectopic pregnancy: criteria to choose therapy

The ectopic pregnancy (EP) could be treated by spontaneous resolution, or medical treatment or laparoscopic treatment. Spontaneous resolution of EP with beta hCG < 1,000 mUl/ml, plasmatic progesterone < 5 ng/ml had 74% success rate. Methotrexate (MTX) injection is the common Medical treatment of EP with beta hCG < or = 5,000 mUl/ml and mean diameter of EP < or = 3 cm: a single dose of 50 mg/m2 or 1 mg/kg intramuscular injection had 93.4% success rate; local injection under sonographic control (1 mg/kg) had 80.2% success rate. The surgical conservative treatment by laparoscopy had 94% success rate.     

Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures

PURPOSE: We review the applications and outcomes of penile circular fasciocutaneous flap urethroplasty in 66 patients at our institution. MATERIALS AND METHODS: We used a circular distal penile skin flap for urethral reconstruction in 66 men with complex urethral strictures. Average stricture length in this series was 9.08 cm. and mean followup was 41 months (range 1 to 7 years). RESULTS: The initial overall success rate was 79% (52 of 66 cases). Recurrent stenosis was noted in 7 of the 54 onlay (13%) and 7 of the 12 tubularized repairs (58%). Most recurrent strictures were successfully treated with a single subsequent procedure, including repeat urethroplasty in 5 cases and optical urethrotomy or dilation in 6. Two patients required perineal urethrostomy and 1 awaits further reconstruction. Including subsequent procedures, the overall long-term followup success rate was 95%. Neurovascular lower extremity complications developed in 4 patients after prolonged high lithotomy positioning. CONCLUSIONS: Circular fasciocutaneous flap urethroplasty is a highly effective 1-stage method of reconstructing complex urethral strictures. Onlay repairs appear to be more successful than those involving flap tubularization. Limiting the time that the patient spends in the high lithotomy position appears to prevent neurovascular extremity complications.     

Serum pregnancy-specific beta1-glycoprotein before embryo transfer is related to endometrial thickness and to outcome prognosis in women undergoing in-vitro fertilization treatment

We have previously observed the repeated presence of low but detectable amounts of the trophoblast marker pregnancy-specific beta1-glycoprotein (SP1) in the serum of some women undergoing in-vitro fertilization (IVF) treatment around the time of oocyte retrieval. The occurrence of these signals seemed to be restricted to a defined group of patients which also showed a lower pregnancy success rate in a preliminary study. To test our hypothesis we have analysed 173 consecutive cycles leading to an embryo transfer. Fifty-four cycles (31%) had a serum SP1 level of at least 0.1 ng/ml between days embryo transfer -5 and embryo transfer (group A). Five pregnancies were obtained in this group (pregnancy rate = 9.3%), while in group B, defined by the absence of detectable SP1 before embryo transfer (119 cycles), 36 ongoing pregnancies were achieved (30.3%). Ten of the 41 pregnancies were achieved in 33 first-time non-pregnant patients undergoing further attempts during the study period. Again the pregnancy rate was higher in the first-time group B women (9/23 versus 1/10 for group A). Patients tended to remain in their groups A or B, the latter being associated with a better immediate as well as subsequent chance for pregnancy. Group A cycles had a significantly lower endometrial thickness two days before oocyte retrieval than group B (P = 0.0011). We postulate that the presence of an unknown, maternal and progesterone- or follicle stimulating hormone-independent factor in some patients could stimulate tonic ectopic SP1 synthesis and at the same time negatively influence endometrial development.     

Successful treatment of advanced interstitial pregnancy with methotrexate and hysteroscopy. A case report

BACKGROUND: Data concerning medical treatment of interstitial ectopic pregnancies are scarce. These pregnancies are characterized by late and serious clinical manifestations. We report a case of advanced interstitial pregnancy treated successfully by combining methotrexate (MTX) and hysteroscopy. CASE: A routine ultrasonic evaluation of a 10-week pregnancy revealed a right interstitial gestational sac 58 mm in diameter and containing an embryo with a crownrump length of 29 mm and embryonic heartbeats. Serum beta-human chorionic gonadatropin (hCG) level was 97,950 mIU/mL. The patient was treated with a systemic MTX/leucovorin regimen. At the end of the one-week course, no embryonic cardiac activity was detected, and a decrease in beta-hCG levels commenced. Persistent trophoblastic tissue, manifested by a low (26 mIU/mL) beta-hCG level in plateau, was successfully removed by way of hysteroscopy. CONCLUSION: Early detection of interstitial pregnancy may facilitate conservative medical treatment.     

Plasma albumin induces calcium waves in rat cortical astrocytes

At the end of the 19th century, ectopic pregnancy became a surgical procedure. A century later, one third of ectopic pregnancies are treated medically. In the meantime, early detection of ectopic pregnancy became possible due to sensitive serum hCG and progesterone combined assays with transvaginal sonography and a knowledge of risk factors. Consequently, a nonsurgical approach appears to be an attractive alternative to surgery. Expectant management is recommended with a plateau or decreasing hCG and an initial level < or = 1.000 mIU/ml in asymptomatic women. Medical treatment by local or parenteral methotrexate is recommended in patients with clear evidence of an unruptured pregnancy in based on initial hCG and progesterone level, size of hemoperitoneum, ultrasound diameter of hematosalpinx and absence of clinical pain. Laparoscopy remains the gold standard but in prospective randomized trials between medical treatment and laparoscopy, in selected patients, the non-surgical approach appears to be equivalent with a similar reproductive performance.     

The use of clomiphene citrate

Two hundred and fifty-five women received clomiphene citrate during a 10-year period. Fifty-six were treated diagnostically and one hundred and ninty-nine therapeutically for infertility. It is concluded that clomiphene may aid in confirming the diagnosis and establishing a prognosis in patients with primary or secondary amenorrhea. The success of clomiphene therapy in patients with anovulatory infertility is related to the etiologic factor responsible for the anovulation, but results can be improved by adjustment of the therapeutic regimen used. In the present series, 48% of the patients who ovulated became pregnant, and 25.3% of the pregnancies were miscarried. Those patients who ovulated spontaneously and became pregnant after having discontinued clomiphene therapy showed only a 10% abortion rate. A review of the results indicates that both the ovulation rate and the pregnancy rate can be improved if adjustments are made in therapy to ensure normal follicular maturation and corpus luteum function.     

Variability of cutaneous lymphatic flow rates in melanoma patients

A woman with a small (6-mm gestational sac) interstitial pregnancy had complete resolution after medical therapy alone. A single cycle of methotrexate 50 mg/m2 was used as outpatient treatment without any operative procedure either for diagnosis or intervention. The guidelines that have evolved for selection of women for single dose methotrexate treatment for both intrauterine and tubal ectopic pregnancies may be applicable to interstitial ectopic pregnancy as well. A suggested framework for treatment decisions is presented.     

Diagnosis of ectopic pregnancy--why we need a protocol

OBJECTIVE: To audit the management after instituting a screening programme for ectopic pregnancy in an institution with a protocol utilising ultrasound examination and serial human chorionic gonadotropin (hCG) and to examine the risk of missed diagnosis with deviation from the protocol. MATERIAL AND METHOD: A retrospective analysis of the management of 145 symptomatic patients in early pregnancies without intrauterine gestational sacs from ultrasound examinations, during the period April to June 1994 in Kandang Kerbau Hospital. Patients underwent serial hCG tests over 48 hours with or without repeat ultrasound scans before definitive treatment unless clinical indications for emergency surgery was necessary. RESULTS: There were 35 ectopic pregnancies (24%), 16 were viable intrauterine pregnancies (11%), 87 were non-viable pregnancies (60%) and 7 were of unknown outcome. There were much practice deviations from the protocol. Forty-four percent (64 cases) of the management decisions were made based on the initial clinical and ultrasound findings, and another 14% (21 cases) after a repeat assessment within the next day by either a repeat scan or serial serum hCG over one day. Among them, two of the 29 operated for suspected ectopic pregnancy were not ectopic (7%) and two of the 56 thought not to be ectopic, turned out to be ectopic (4%) (p < 10(-8)). Six percent (8 cases) defaulted after the initial assessments and one of them was found to be ectopic subsequently. Thirty percent (43 cases) adhered to the protocol. They had serial serum hCG done over two days. Seven of them requiring further repeats of serial serum hCG before management decisions were made. Four patients who were operated on were confirmed ectopic and 39 patients not operated on were not ectopic. Three percent (5 cases) were managed by serial hCG over 3 to 5 days and another 3% (4 cases) by repeating scan over one to two weeks without serial hCG. None of these was ectopic. The percentage change of hCG levels over two days gave indications of the likely diagnosis. CONCLUSION: Adhering to a protocol utilising the principle of ultrasound scan, serial hCGs and selective repeat ultrasound scans are highly recommended for the diagnosis of ectopic pregnancy. Any deviation from protocol is dangerous, with a 4% risk of missing an ectopic and a 7% risk of unnecessary operation for suspected ectopic pregnancy.     

Flashlamp pulsed dye laser (585 nm). Treatment of resistant verrucae

The treatment of recalcitrant plantar verrucae has represented challenging clinical problems for podiatric physicians. A procedure described by Borovoy et al studying 46 patients initially indicated a success rate of 76.1%. A review of 200 patients who have been treated with refined treatment protocols and modalities is presented, with an overall success rate of 79.9%. The Candella SPTL 1 and 1B have been used in the study. These lasers produce a full 450-microsecond pulse at 585 nm wave length. Hand pieces ranging from 2 mm to 7 mm were used. The energy density (fluence) used ranged from 6 to 9 J/cm2. Discussion will be presented including treatment protocol, modalities, comparisons with other forms of treatment, and overall success rates.