Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test

The ampulla portion of the fallopian tube is the most common site of ectopic pregnancy (70%), with approximately 2% of pregnancies implanted in the interstitial portion. In general, an interstitial ectopic pregnancy (IEP) is difficult to diagnose and is associated with a high rate of complications-most patients with an IEP present with severe abdominal pain and haemorrhagic shock due to an ectopic rupture. Chronic tubal pregnancy (CTP) is an uncommon condition with an incidence of 20%. The CTP has a longer clinical course and a negative or low level of serum beta-human chorionic gonadotropin due to perished chorionic villi. This study presents a case of a woman who was diagnosed with a chronic IEP (CIEP) which was successfully treated by surgery. This case also acts as a cautionary reminder of considering a CIEP in women of reproductive age presenting with amenorrhea, vaginal bleeding and a negative pregnancy test.

Can video-based telehealth examinations of the abdomen safely determine the need for imaging?

There is little evidence on the reliability of the video-based telehealth physical examinations. Our objective was to evaluate the feasibility of a physician-directed abdominal examination using telehealth. This was a prospective, blinded observational study of patients >19 years of age presenting with abdominal pain to a large, academic emergency department. In addition to their usual care, patients had a video-based telehealth examination by an emergency physician early in the visit. We compared the in-person and telehealth providers' decisions on imaging. Thirty patients were enrolled and providers' recommendations for imaging were YES (telehealth: 18 (60%); in-person: 22 (73%)), UNSURE (telehealth: 9 (30%); in-person: 2 (7%)) and NO (telehealth: 6 (20%); in-person: 3 (10%)). There were 20 patients for whom both telehealth and in-person providers were not unsure; of these, 16 (80%, 95% confidence interval 56.3-94.3%) patients had a provider agreement on the need for imaging. While the use of video-based telehealth may be feasible for patients seeking emergency department care for abdominal pain, further study is needed to determine how it may be safely deployed. Currently, caution should be exercised when evaluating the need for abdominal imaging remotely.

Can tablet video-based telehealth assessment of the abdomen safely determine the need for abdominal imaging? A pilot study

Objective

There is limited evidence on the reliability of video-based physical examinations. We aimed to evaluate the safety of a remote physician-directed abdominal examination using tablet-based video.

Methods

This was a prospective observational pilot study of patients >19 years old presenting with abdominal pain to an academic emergency department July 9, 2021-December 21, 2021. In addition to usual care, patients had a tablet video-based telehealth history and examination by an emergency physician who was otherwise not involved in the visit. Both telehealth and in-person clinicians were asked about the patient's need for abdominal imaging (yes/no). Thirty-day chart review searched for subsequent ED visits, hospitalizations, and procedures. Our primary outcome was agreement between telehealth and in-person clinicians on imaging need. Our secondary outcome was potentially missed imaging by the telehealth physicians leading to morbidity or mortality. We used descriptive and bivariate analyses to examine characteristics associated with disagreement on imaging needs.

Results

Fifty-six patients were enrolled; the median age was 43 years (interquartile range: 27-59), 31 (55%) were female. The telehealth and in-person clinicians agreed on the need for imaging in 42 (75%) of the patients (95% confidence interval [CI]: 62%-86%), with moderate agreement with Cohen's kappa ((k = 0.41, 95% CI: 0.15-0.67). For study patients who had a procedure within 24 hours of ED arrival (n = 3, 5.4%, 95% CI: 1.1%-14.9%) or within 30 days (n = 7, 12.5%, 95% CI: 5.2%-24.1%), neither telehealth physicians nor in-person clinicians missed timely imaging.

Conclusion

In this pilot study, telehealth physicians and in-person clinicians agreed on the need for imaging for the majority of patients with abdominal pain. Importantly, telehealth physicians did not miss the identification of imaging needs for patients requiring urgent or emergent surgery.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

The Predictive Value of Decisive and Soft Ultrasound Criteria for Ectopic Pregnancy Identification in 321 Preoperative Cases

PURPOSE

 To define the predictive value of morphological types (MTs) and further criteria in diagnosing ectopic pregnancy (ECP) by transvaginal sonography (TVS) prior to operative confirmation and treatment.

MATERIALS AND METHODS

 Retrospective cohort analysis of 321 consecutive patients with suspected ECP who were advised to undergo operation.

RESULTS

 ECP was investigated by TVS in all 321 patients. Application of the five selected MTs (blob sign, bagel sign, yolk sac, embryo, heart action) resulted in 85 % of cases receiving a conclusive diagnosis and 12 % receiving a presumed ECP diagnosis. 3 % remained nondiagnostic due to large or multiple ovarian cysts, large myoma, extended hemoperitoneum, or severe pain. ECP diagnosis was confirmed intraoperatively in 97 % of cases and was otherwise (3 %) immediately followed by curettage (CUR). The assessment of free fluid by TVS was achieved in most cases and correlated significantly with free blood. In the majority of cases, free blood was not bound to transmural ECP rupture. Histology confirmed the ECP diagnosis directly or by exclusion in 99 % of cases. Three cases of tubal ECP were diagnosed by TVS but not confirmed by LSC (1 %) and, finally, histology from CUR proved miscarriage (false-positive rate 1 %).

CONCLUSION

 We confirm the high accuracy of TVS diagnosis of ECP relying on five clearly different MTs, independent of its location. The blob and bagel sign emerged as important types (75 % of all ECPs). Histology from CUR was needed when ECP could not be visualized in LSC. Assessment of free fluid was essential and accurate in predicting free blood.

Middle-East obgyn graduate education (MOGGE) foundation practice guidelines: diagnostic approach to pregnancy of unknown location: practice guideline no. 03-O-21

Background

Pregnancy of unknown location (PUL) is a term used to describe failure of visualization of intrauterine or extrauterine gestational sac in a woman with a positive pregnancy test.

Body of the abstract

Ectopic pregnancy (EP) accounts for 1–2 % of all pregnancies. EP contributes to maternal mortality of a known cause by 4% in developed countries. However, case fatality rate may be 10 times higher in low-resource countries. This may be attributed to delayed diagnosis and lack of resources. PUL is a temporary term that may eventually lead to diagnosis of viable intrauterine pregnancy, pregnancy loss, or more seriously, EP.

Conclusion

This guideline appraises current evidence on assessment of PUL and early diagnosis of EP particularly in low-resource settings.

Pregnancy of unknown location: external validation of the hCG-based M6NP and M4 prediction models in an emergency gynaecology unit

OBJECTIVE

To investigate if M6NP predicting ectopic pregnancy (EP) among women with pregnancy of unknown location (PUL) is valid in an emergency gynaecology setting and comparing it with its predecessor M4.

DESIGN

Retrospective cohort study.

SETTING

University Hospital.

PARTICIPANTS

Women with PUL.

METHODS

All consecutive women with a PUL during a study period of 3 years were screened for inclusion. Risk prediction of an EP was based on two serum human chorionic gonadotropin (hCG) levels taken at least 24 hours and no longer than 72 hours apart.

MAIN OUTCOME MEASURES

The area under the ROC curve (AUC) expressed the ability of a model to distinguish an EP from a non-EP (discrimination). Calibration assessed the agreement between the predicted risk of an EP and the true risk (proportion) of EP. The proportion of EPs and non-EPs classified as high risk assessed the model's sensitivity and false positive rate (FPR). The proportion of non-EPs among women classified as low risk was the model's negative predictive value (NPV). The clinical utility of a model was evaluated with decision curve analysis.

RESULTS

1061 women were included in the study, of which 238 (22%) had a final diagnosis of EP. The AUC for EP was 0.85 for M6NP and 0.81 for M4. M6NP made accurate risk predictions of EP up to predictions of 20% but thereafter risks were underestimated. M4 was poorly calibrated up to risk predictions of 40%. With a 5% threshold for high risk classification the sensitivity for EP was 95% for M6NP, the FPR 50% and NPV 97%. M6NP had higher sensitivity and NPV than M4 but also a higher FPR. M6NP had utility at all thresholds as opposed to M4 that had no utility at thresholds≤5%.

CONCLUSIONS

M6NP had better predictive performance than M4 and is valid in women with PUL attending an emergency gynaecology unit. Our results can encourage implementation of M6NP in related yet untested clinical settings to effectively support clinical decision-making.

Undisturbed tubal pregnancies with positive fetal heart treated medically: Case study

The incidence of ectopic pregnancy (EP) is 1.3-2.4%. Suspicion of EP starts after a positive serum pregnancy test and failure to visualize the intrauterine gestational sac (GS) by transvaginal sonography (TVS). About 88% of tubal EPs are diagnosed by absent intrauterine GS and the presence of an adnexal mass during TVS. Medical treatment of EP using methotrexate (MTX) is cost-effective with a similar success rate to surgical treatment. The presence of fetal heart beats, β-human chorionic gonadotropin >5000 mIU/mL, and EP size >4 cm are relative contraindications for using MTX in the treatment of EP.

Idiopathic spontaneous haemoperitoneum at 4 weeks gestation

A 20-year-old nulliparous patient with acute-onset abdominal pain and imaging suggestive of haemoperitoneum was admitted for observation. Though, initially, haemodynamically stable, her clinical picture worsened throughout her hospitalisation and warranted two separate laparoscopies that revealed 1200 mL and 50 mL of haemoperitoneum, respectively, without an identifiable bleeding source. After serial β-human chorionic gonadotropin levels and ultrasound confirmation of a viable pregnancy 23 days later, the patient underwent a normal antenatal course and delivered a healthy infant at 37 weeks gestation. This unusual case highlights the need to consider spontaneous haemoperitoneum in pregnancy as a diagnosis, particularly in the setting of pregnancy of unknown location, even at an early stage of pregnancy.

The diagnostic utility of placental growth factor in ectopic pregnancy

PURPOSE

Ectopic pregnancy is a condition of enormous gynaecological priority. It occurs when fertilized ovum implants outside the uterine cavity. Ectopic pregnancy is estimated to be 1-2% of all-natural conception. This study aims to evaluate the role of the placental growth factor in the diagnosis of ectopic pregnancy.

METHODS

A case-control study was conducted in (Baghdad) teaching hospital in (Baghdad, Iraq) over one year. The study includes 240 women: 120 women with first trimester (5-10) weeks viable intrauterine pregnancy, and 120 women with ectopic pregnancy.

RESULTS

There is a significant association observed in the placental growth factor mean (PLGF), which is lower in ectopic pregnancy than in intrauterine pregnancy. The range of PLGF was less than 50 pg/mL in ectopic pregnancy, while it was up to 800 pg/mL in intrauterine pregnancy. In an ectopic pregnancy with a cut-off PLGF level of ≤ 15.5 pg/mL, the PLGF had a sensitivity of (92.5%), a specificity of (82.5%), a positive predictive value of (91.8%), a negative predictive value of (83.5%), and an accuracy of (90%). Different factors can affect PLGF, like the parity and body mass index.

CONCLUSION

The serum level of the placental growth factor seems to be a promising biomarker for diagnosing ectopic pregnancy because a highly significant difference was found between healthy and ectopic pregnancy.

A classic case suggestive of an unruptured ectopic pregnancy with unexpected finding of a unilateral dermoid cyst intraoperatively: A case report

Acute lower abdominal pain or pelvic pain is a common presenting complaint in women of reproductive age, which can be accounted for by numerous aetiologies. The presentation of lower abdominal pain with associated findings of an adnexal mass on transvaginal ultrasonography and positive beta-human chorionic gonadotropin (β-hCG) (serum and urine) in a sexually active woman of reproductive age is an ectopic pregnancy until proven otherwise. Here, we present a classic case suggestive of an unruptured ectopic pregnancy, with an unexpected finding of a unilateral dermoid cyst intraoperatively in a 33-year-old woman. Findings presented herein suggest that practitioners in our local setting should evaluate patients carefully, and consider neoplasms as a possible source of β-hCG production in sexually active women of reproductive age who present with subacute lower abdominal pain, identified adnexal mass on ultrasonography and positive serum or urine β-hCG readings.

Heterotopic Pregnancy Diagnosed with Point-of-care Ultrasound in the Emergency Department: A Case Report

Introduction

Heterotopic pregnancies are rare. However, they are occurring with increasing frequency. Unfortunately, diagnosis is frequently delayed, with patients presenting in extremis.

Case Report

We present a case of a heterotopic pregnancy diagnosed by point-of-care ultrasound (POCUS) in a woman presenting with lower abdominal pain, who had a documented normal first trimester ultrasound the day prior to presentation.

Discussion

Given the increasing rates of heterotopic pregnancies, we can no longer be reassured by the presence of an intra-uterine pregnancy (IUP) in a patient with concerning signs and symptoms of a ruptured ectopic pregnancy. A thorough POCUS evaluation of the uterus and adnexa is essential for the diagnosis of heterotopic pregnancy in the emergency department.

Conclusion

This case highlights the value POCUS brings to the emergency department evaluation of patients in early pregnancy.

Ectopic pregnancy following oral levonorgestrel emergency contraception use

Levonorgestrel is used worldwide as an emergency oral contraceptive. There have been occasional reports of ectopic pregnancy after oral levonorgestrel use. We present a case of ectopic tubal pregnancy after the use of oral levonorgestrel as an emergency contraceptive in a 37-year-old woman with a history of treatment for Chlamydia trachomatis infection. She conceived after sexual intercourse on menstrual day 14 of the first menstrual cycle following a normal delivery. After salpingectomy for this right tubal pregnancy, her following pregnancy was an ectopic pregnancy in the contralateral tube, which was treated with laparoscopic salpingectomy. Histopathological examination revealed endometriosis. We should be aware of ectopic pregnancy even after emergency contraceptive use, especially in patients with risk factors, such as Chlamydia infection and endometriosis. Because the efficacy of levonorgestrel decreases after ovulation, we should check the stage of the cycle before prescription.

Multidosing Intramuscular Administration of Methotrexate in Interstitial Pregnancy With Very High Levels of β-hCG: A Case Report and Review of the Literature

Ectopic pregnancy (EP) is the implantation of an embryo outside the endometrial cavity of the uterus. Signs and symptoms of EP may arise between the 6th and the 8th week of gestation and include vaginal bleeding, lower abdominal and pelvic pain. Frequently EPs implant in the fallopian tubes. A rare EP is the interstitial pregnancy, a life-threatening condition being responsible for nearly 20% of all deaths caused by EPs. Because of its unique location, the diagnosis is difficult and based on signs and specific criteria together with measuring of serum β-hCG. Usually, EP is treated by surgical approach, which is associated with increased morbidity, decreased fertility and increased likelihood of hysterectomy and uterine rupture in a subsequent pregnancy. Early diagnosis is crucial to life saving and allowing alternative therapeutic interventions such as pharmacological treatments. Methotrexate (MTX) represents the mainstay therapy. There is no standard care for the interstitial pregnancy for what concerns either surgical or pharmacological approaches. We reported a case of a 36-year-old woman admitted to the Hospital of Salerno-Italy with a value of serum β-hCG of 35,993 IU/L. Transvaginal ultrasonography revealed an empty uterine cavity and a mass of 35.7 mm in diameter characterized by a hypoechoic central area. The patient was in stable haemodynamic condition and no haematologic, renal and hepatic impairments were recorded. Despite the high serum β-hCG levels, a pharmacological approach was preferred to a surgical one. The patient was treated with intramuscular administration of MTX in daily dose of 1 mg/Kg alternated with 0.1 mg/kg folinic acid for 5 days. The patient remained hospitalized for 20 days and no side effects were reported. The decrease of the serum β-hCG was monitored and more than 15% reduction was detected between the 4th and the 7th day after the beginning of the treatment. The serum β-hCG became undetectable 35 days after. A multidosing intramuscular administration of MTX was effective and safe even in the presence of very high serum β-hCG levels. Together with similar cases reported in literature, the present results can contribute to improve the decision making in the treatment of the interstitial pregnancy.

How to measure size of tubal ectopic pregnancy on ultrasound

OBJECTIVE

To identify the preoperative ultrasound parameters for assessing the size of tubal ectopic pregnancy that correlate best with findings at surgery.

METHODS

This was a prospective study of all women attending our center who had a conclusive transvaginal ultrasound diagnosis of tubal ectopic pregnancy over a 10-month period. In each case, the total size of the ectopic pregnancy was measured by placing the calipers on the outer edges of the visible trophoblastic tissue. In ectopic pregnancies presenting with a well-defined gestational sac, the size of the celomic (chorionic) cavity was also measured using the inner borders of the trophoblastic ring as reference points. In women with signs of intra-abdominal bleeding, the size of the hematosalpinx and/or hemoperitoneum was measured. Surgeons were blinded to the ultrasound measurements and were asked to estimate the size of the ectopic pregnancy and the amount of hemoperitoneum intraoperatively.

RESULTS

A total of 105 women were diagnosed with a tubal ectopic pregnancy on ultrasound examination, of whom 71 (67.6%) were managed surgically. A significant (P < 0.01) positive correlation was found between all ultrasound measurements and the size of the tubal ectopic pregnancy as reported during surgery. In the absence of hematosalpinx, the mean total outer diameter of the ectopic pregnancy had the highest positive correlation with the size of the tubal ectopic pregnancy at surgery (r = 0.65, P < 0.001). In cases complicated by hematosalpinx, the mean diameter of the tube was the only variable that correlated significantly with the estimated size of the ectopic pregnancy at surgery (P < 0.001). There was a significant positive association between the amount of hemoperitoneum on ultrasound and the estimated volume of intraperitoneal blood at surgery (P < 0.001).

CONCLUSIONS

The mean size of a hematosalpinx and the total outer mean diameter of an ectopic pregnancy on ultrasound correlate better with the surgical findings than does the size of the celomic cavity. Our findings show that the standard approach of measuring the size of an intrauterine pregnancy on ultrasound should be adapted to include these additional measurements in women diagnosed with a tubal ectopic pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Occurrence of spontaneous bilateral tubal pregnancy in a low-income setting in rural Cameroon: a case report

Background

Ectopic pregnancy is a life-threatening emergency warranting immediate recognition and prompt intervention. Bilateral tubal pregnancy is the rarest form of ectopic pregnancy with very limited data on its occurrence reported in sub-Saharan Africa.

Case presentation

We report the case of a 40-year-old multigravida with chief complains of lower abdominal pain evolving for 5 days in whom an intraoperative diagnosis of spontaneous bilateral tubal pregnancy (plus ruptured right tube) was made.

Conclusions

Ectopic pregnancy is one of the major causes of maternal mortality in sub-Saharan Africa. Thus, clinicians should maintain a high index of suspicion, even in the absence of hallmark features and thorough clinical examination undertaken especially in resource-limited settings. Examination of both tubes at laparotomy for ectopic pregnancy should be routine and mandatory.

Evaluation of clinical effect of transabdominal sonography and transvaginal sonography in early diagnosis of ectopic gestation

Objective:

To analyze the application of transabdominal sonography and transvaginal sonography in early diagnosis of pregnancy and to provide a reference for the selection of diagnosis methods in clinic.

Methods:

One hundred and eighty patients who were admitted into the hospital from February 2013 to February 2014, received clinical diagnosis and were confirmed as ectopic gestation by surgery were selected as research objects. They were examined by transabdominal sonography, transvaginal sonography, and transabdominal sonography in combination with transvaginal sonography respectively. Besides, the ultrasonic performance was observed and compared with surgical pathological results to analyze and compare diagnostic accordance rate.

Results:

The positive rate of transabdominal sonography in combination with transvaginal sonography was much higher than that of transabdominal sonography and transvaginal sonography and the differences had statistical significance (P<0.05). The detection rate of different positive characteristics using the combined examination was much higher than that of transabdominal sonography and transvaginal sonography, and the differences had statistical significance (P<0.05). The detection rates of different types of ectopic gestation and different sizes of mass using transabdominal sonography in combination of transvaginal sonography were higher than that of transabdominal sonography and transvaginal sonography (P<0.05).

Conclusion:

Transabdominal sonography in combination with transvaginal sonography can complement information, improve detection rate, and reduce or avoid misdiagnosis and missed diagnosis, which provides a scientific basis for the formulation of clinical treatment scheme.

Rare Site of Ectopic Pregnancy in a Patient with Bicornuate Uterus

Ectopic pregnancy occurs in about 1-2% in normal cycles but in IVF cycles the rate jumps to 4%. No definite cause for ectopic pregnancy was detected, but many risk factors were described as abnormal tube, pelvic infection, or surgery. In this case report we found 2 abnormalities in eight-year infertile woman; the first abnormality was bicornuate uterus and the second abnormality was the site of ectopic pregnancy which was in between the two horns of uterus. ‎This is the only case reported with primary abdominal pregnancy with bicornuate uterus and both healthy ovaries and tubes.‎ The case was unstable and managed by laparotomy and repair of ectopic site after enucleation of sac using Vicryl 2/0. The case was discharged 24 hours after operation in good health.

The Diagnosis and Treatment of Ectopic Pregnancy

BACKGROUND

Extrauterine pregnancy is a complication of the first trimester of pregnancy that arises in 1.3-2.4% of all pregnancies.

METHODS

This review is based on articles and guidelines retrieved by a selective PubMed search.

RESULTS

The presentation of extrauterine pregnancy is highly variable, ranging from an asymptomatic state, to pelvic pain that is worse on one side, to tubal rupture with hemorrhagic shock. 75% of tubal pre gnancies can be detected by transvaginal ultrasonography. In patients with a vital extrauterine pregnancy, the human chorionic gonadotropin concentration generally doubles within 48 hours. Laparoscopy is the gold standard of treatment. Two randomized, controlled trials comparing organ-preserving treatment with ablative surgery revealed no significant difference in pregnancy rates after the intervention, but precise details of the surgical procedures were not provided, and long-term fertility data are lacking. Metho - trexate therapy should be used only for strict indications.

CONCLUSION

Further randomized, controlled trials with longer follow-up will be needed to answer currently open questions about the potential for individualized surgical treatment and the proper role of pharmacotherapy.

Predicting first trimester pregnancy outcome: derivation of a multiple marker test

OBJECTIVE

To predict first trimester pregnancy outcome using biomarkers in a multicenter cohort.

DESIGN

Case-control study.

SETTING

Three academic centers.

PATIENT(S)

Women with pain and bleeding in early pregnancy.

INTERVENTION(S)

Sera from women who were 5-12 weeks' gestational age with ectopic pregnancy (EP), viable intrauterine pregnancy (IUP), and miscarriage/spontaneous abortion (SAB) was analyzed by ELISA and immunoassay for activin A, inhibin A, P, A Disintegrin And Metalloprotease-12, pregnancy-associated plasma protein A (PAPP-A), pregnancy specific B1-glycoprotein (SP1), placental-like growth factor, vascular endothelial growth factor, glycodelin (Glyc), and hCG. Classification trees were developed to optimize sensitivity/specificity for pregnancy location and viability.

MAIN OUTCOME MEASURE(S)

Area under receiver operating characteristic curve, sensitivity, specificity, and accuracy of first trimester pregnancy outcome.

RESULT(S)

In 230 pregnancies, the combination of trees to maximize sensitivity and specificity resulted in 73% specificity (95% confidence interval (CI) 0.65-0.80) and 31% sensitivity (95% CI 0.21-0.43) for viability. Similar methods had 21% sensitivity (95% CI 0.12-0.32) and 33% specificity (95% CI 0.26-0.41) for location. Activin A, Glyc, and A Disintegrin And Metalloprotease-12 definitively classified pregnancy location in 29% of the sample with 100% accuracy for EP. Progesterone and PAPP-A classified the viability in 61% of the sample with 94% accuracy.

CONCLUSION(S)

Multiple marker panels can distinguish pregnancy location and viability in a subset of women at risk for early pregnancy complications. This strategy of combining markers to maximize sensitivity and specificity results in high accuracy in a subset of subjects. Activin A, ADAM12, and Glyc are the most promising markers for pregnancy location; P and PAPP-A for viability.

Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy

Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.

The 100 most cited articles in ectopic pregnancy: a bibliometric analysis

Ectopic pregnancy (EP) remains a major gynecological emergency and is a cause of morbidity or even mortality in women. As a consequence, top citation analysis of EP research in database of the Science Citation Index Expanded is needed to assess the publication trends of leading countries/territories and institutes as well as the research hotspots of EP. A total of 4881 articles relevant to EP were retrieved in the database of the Science Citation Index Expanded from 1965 to present, in which the 100 top-cited articles were selected for further analysis. The number of citations ranged from 81 to 482 (131.57 ± 69.76), with a time span of 40 years between 1969 and 2009. These citation classics came from 14 countries, and 65 of the articles came from the United States. Yale University in Connecticut led the list of classics with six papers. The 100 top-cited articles were published in 32 journals, in which the journal of Fertility and Sterility published the most (23 papers). Stovall TG and Ling FW published the highest number of studies (6 papers each). Articles that originated in the United States and that were published in high-impact journals were most likely to be cited in the field of EP research. Bibliometric analysis was used to provide a historical perspective on the progress in EP research over the past 50 years. Citation analysis is a feasible tool to comprehensively recognize the advances of EP research in the past and future research.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay

BACKGROUND

The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS).

METHODS

This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment.

RESULTS

We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01).

CONCLUSION

In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.

Recurrent ectopic pregnancy as a unique clinical sub group: a case control study

BACKGROUND

Women with recurrent ectopic pregnancy (EP) represent a unique cohort of patients in whom diagnostic expertise is paramount. We determined whether recurrent EP is associated with significant differences in patient demographics, clinical presentation, risk factors and surgical findings when compared with primary EP.

METHODS

A retrospective case-control study of all EPs diagnosed from 2003 to 2014, at Whipps Cross University Hospital, London.

RESULTS

In the above period 849 EPs were surgically managed (758 primary EPs and 91 recurrent EPs). Recurrent EPs were significantly older than primary EPs (32.2 ± 5.08 vs. 30.5 ± 5.83 years, p < 0.05). They presented at a significantly earlier gestation (5.99 ± 1.08 vs. 6.52 ± 1.81 weeks, p < 0.05) and with a significantly lower primary βHCG (3176 ± 7350 vs. 6243 ± 12,282, p < 0.05). Recurrent EPs were significantly more likely to have a positive history of tubal or pelvic surgery (61.5 % vs. 3.5 %, p < 0.05 and 53.8 vs. 14 %, p < 0.05). At surgery, primary EPs had a significantly greater volume of hemoperitoneum (592 ± 850 vs. 249 ± 391 ml, p < 0.05), whereas recurrent EPs were significantly more likely to have contralateral pathology (31.1 vs. 9.8 %, p < 0.05). Regression analysis showed that the parameters of age, gestational age at presentation, first βHCG level, positive history of previous tubal surgery and previous ectopic pregnancy differ in women at risk of a recurrent EP when compared to women not at risk of a recurrent ectopic (AUC, 0.844).

CONCLUSIONS

We conclude that recurrent EPs may represent a unique sub-group of patients with EP.

Eligibility criteria in systematic reviews published in prominent medical journals: a methodological review

RATIONALE AND AIM

Clear and logical eligibility criteria are fundamental to the design and conduct of a systematic review. This methodological review examined the quality of reporting and application of eligibility criteria in systematic reviews published in three leading medical journals.

METHODS

All systematic reviews in the BMJ, JAMA and The Lancet in the years 2013 and 2014 were extracted. These were assessed using a refined version of a checklist previously designed by the authors.

RESULTS

A total of 113 papers were eligible, of which 65 were in BMJ, 17 in The Lancet and 31 in JAMA. Although a generally high level of reporting was found, eligibility criteria were often problematic. In 67% of papers, eligibility was specified after the search sources or terms. Unjustified time restrictions were used in 21% of reviews, and unpublished or unspecified data in 27%. Inconsistency between journals was apparent in the requirements for systematic reviews.

CONCLUSIONS

The quality of reviews in these leading medical journals was high; however, there were issues that reduce the clarity and replicability of the review process. As well as providing a useful checklist, this methodological review informs the continued development of standards for systematic reviews.

ACUTE PELVIC PAIN IN THE ADOLESCENT: A CASE REPORT

Diagnosis and treatment of acute pelvic pain in the adolescent female requires differentiating among a broad differential diagnosis that includes potentially serious illness across several organ systems. The case presented provides an illustration of the assessment and management of acute pelvic pain, and key teaching points about important potential causes.

Non-invasive tools for the diagnosis of potentially life-threatening gynaecological emergencies: a systematic review

OBJECTIVE

To identify non-invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy.

METHODS

MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 × 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility ≥ 95% and LR-≤ 0.25, or Specificity ≥ 90% and LR+ ≥ 4.

RESULTS

We identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure<110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration <10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs.

CONCLUSION

This systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.

Trend of ectopic pregnancy and its main determinants in Hamadan province, Iran (2000-2010)

Background

Ectopic pregnancy remains a major gynaecologyical problem in contemporary gynaecological practice. The purpose of this study was to determine the incidence and some risk factors of ectopic pregnancy in Hamadan province during 2000-2010.

Methods

This was a retrospective descriptive study carried out at hospitals in Hamadan provience, Iran. A total of 872 women with the diagnosis of ectopic pregnancy between 2000 to 2010 were recruited. At initial assessment, 872 medical records were targeted for the assessment, while because of incompleteness of some recorded information, 521 files were finally assessed.

Results

The overall incidence of ectopic pregnancy was estimated to be 2.6 per 1000 recorded pregnancies. While, considerably increased from 1.5 per 1000 pregnancy in 2000 to 4.8 per 1000 pregnancies in 2010. More than half of the women aged 25 to 34 years. 48.2% of selected women were using contraception methods. 5.2%, 14.0% and 5.6% of women had pervious ectopic pregnancy, first or second infertility and pelvic inflammatory diseases, respectively.

Conclusion

Increasing trend of the incidence of ectopic pregnancy is expected due to development and availability of minute diagnostic approaches and also some baseline amendable (contraceptive methods and surgical interventions) and unchangeable (age of pregnancy and residency) parameters.

Ultrasound imaging in the management of bleeding and pain in early pregnancy

Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.