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AIUM Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound. J Ultrasound Med 2024. [PMID: 38224490 DOI: 10.1002/jum.16406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/17/2024]
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Pape J, Bajka A, Seifert B, Asmis L, Imesch P, Metzler J, Burkhardt T, Condous G, Samartzis EP, Bajka M. Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery - The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood. Ultraschall Med 2023; 44:614-622. [PMID: 36657460 DOI: 10.1055/a-1967-2134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency. METHODS Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves. RESULTS Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794-0.879) and high urgency (AUC 0.902, 95 % CI 0.860-0.945). CONCLUSION Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.
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Affiliation(s)
- Janna Pape
- Gynecology, University Hospital Zurich, Zurich, Switzerland
- Gynecologic Endocrinology and Reproductive Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Anahita Bajka
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Lars Asmis
- Center for perioperative thrombosis and hemostasis, University of Zurich, Zurich, Switzerland
| | - Patrick Imesch
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Julian Metzler
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Tilo Burkhardt
- Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - George Condous
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, University of Sydney - Sydney Medical School Nepean, Sydney, Australia
| | - Eleftherios Pierre Samartzis
- Gynecology, University Hospital Zurich, Zurich, Switzerland
- Gynecology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Michael Bajka
- Gynecology, University Hospital Zurich, Zurich, Switzerland
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Sharma C, Patel H. Ruptured Cornual Ectopic Pregnancy: A Rare and Challenging Obstetric Emergency. Cureus 2023; 15:e47842. [PMID: 38021814 PMCID: PMC10676868 DOI: 10.7759/cureus.47842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Cornual pregnancy is an infrequent form of ectopic pregnancy characterised by the implantation of the embryo at the intersection between the fallopian tube and the uterus. The incidence of ectopic pregnancy is higher in the ampullary region of the fallopian tube. Nevertheless, cornual (interstitial) pregnancy is observed in approximately 2-4% of cases involving ectopic pregnancies. A cornual gestation is considered to be a highly perilous and potentially life-threatening form of ectopic pregnancy, with a mortality rate that is two to five times more than that of other types of ectopic pregnancies. Due to the myometrium's capacity for stretching, the presentation of these cases typically occurs at a later stage, typically between seven and 12 weeks of gestation. Haemodynamic instability is typically observed in patients with ruptured cornual ectopic pregnancy. This study presents a case of a 40-year-old woman, G5P4L1D3, who arrived at the labour room of GMERS (Gujarat Medical Education & Research Society) Medical College and Hospital, Valsad, experiencing shock at eight weeks of gestation. Based on the clinical examination and ultrasound report, a preliminary diagnosis of ruptured cornual ectopic was established. The patient was resuscitated followed by an emergency laparotomy as a critical intervention to preserve their life. The primary approach for addressing maternal mortality caused by cornual pregnancy involves early detection and intervention.
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Affiliation(s)
- Chirag Sharma
- Obstetrics and Gynaecology, GMERS (Gujarat Medical Education & Research Society) Medical College and Hospital, Valsad, IND
| | - Hina Patel
- Obstetrics and Gynaecology, GMERS (Gujarat Medical Education & Research Society) Medical College and Hospital, Valsad, IND
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Hoang BT, Whitaker DW. Ruptured Left Cornual Ectopic Pregnancy: A Case Report. Cureus 2023; 15:e41449. [PMID: 37546046 PMCID: PMC10404111 DOI: 10.7759/cureus.41449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Cornual ectopic pregnancies are rare with a mortality rate that is significantly higher than that of other ectopic pregnancy types. Due to the cornual region's location on the fallopian tube, rupture of a cornual gestation may lead to massive maternal hemorrhage resulting in hypovolemia and shock. Here, we report a 39-year-old female who presented to Hospital Corporation of America (HCA) Florida Healthcare's emergency department (ED) in a state of hypovolemic shock. She was six weeks pregnant based on an unknown and unsure last menstrual cycle. The diagnosis of a ruptured ectopic pregnancy was suspected based on a positive urine pregnancy test and a pelvic ultrasound that revealed an empty uterus and a copious amount of free fluid within the abdomen. Significant hematoperitoneum and hemodynamic instability required emergent exploratory laparotomy with findings of a ruptured left cornual ectopic pregnancy. A left cornual resection and repair was done with an uneventful postoperative period. With cornual ectopic pregnancies being a rare entity, our case emphasizes the importance of early detection and management to help prevent fatal complications.
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Affiliation(s)
- Brittney T Hoang
- Department of Obstetrics and Gynecology, Edward Via College of Osteopathic Medicine Auburn Campus (VCOM-Auburn), Auburn, USA
- Department of Obstetrics and Gynecology, Hospital Corporation of America (HCA) Florida Fort Walton-Destin Hospital, Fort Walton Beach, USA
| | - Donald W Whitaker
- Department of Obstetrics and Gynecology, Hospital Corporation of America (HCA) Florida Fort Walton-Destin Hospital, Fort Walton Beach, USA
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Pape J, Bajka A, Strutas D, Burkhardt T, Imesch P, Fink D, Samartzis EP, Bajka M. The Predictive Value of Decisive and Soft Ultrasound Criteria for Ectopic Pregnancy Identification in 321 Preoperative Cases. Ultraschall Med 2023; 44:e47-e61. [PMID: 33957680 DOI: 10.1055/a-1487-5030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Janna Pape
- Department of Gynecology, University Hospital Zürich, Switzerland
| | - Anahita Bajka
- Department of Obstetrics, University Hospital Zürich, Switzerland
| | | | - Tilo Burkhardt
- Department of Obstetrics, University Hospital Zürich, Switzerland
| | - Patrick Imesch
- Department of Gynecology, University Hospital Zürich, Switzerland
| | - Daniel Fink
- Department of Gynecology, University Hospital Zürich, Switzerland
| | | | - Michael Bajka
- Department of Gynecology, University Hospital Zürich, Switzerland
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Bhat CS, Reddy NS, Vembu R, Pandurangi M. Dual extrauterine ectopic pregnancy: double management. BMJ Case Rep 2021; 14:e244417. [PMID: 34764105 PMCID: PMC8587342 DOI: 10.1136/bcr-2021-244417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old nulliparous woman was referred with suspected left ovarian ectopic pregnancy. She had undergone laparoscopic left salpingectomy for ruptured tubal ectopic pregnancy 3 weeks earlier, following treatment with medications for ovulation induction. Sonological examination revealed a left ovarian ectopic pregnancy corresponding to 8 0/7 weeks with cardiac activity. She underwent ultrasound-guided intrasac therapy with intrasac instillation of 3 mEq of potassium chloride followed by 50 mg of methotrexate. She was followed with weekly measurements of serum beta human Chorionic Gonadotropin (hCG) which returned to baseline after 65 days of the intrasac therapy. This case not only highlights the need for continued follow-up of the serum beta hCG after definitive management of an ectopic pregnancy in cases with multiple ovulations, but also the option of medical management in cases of advanced ovarian ectopic pregnancy. It also accentuates the necessity for adequate counselling to avoid conception in a multiple ovulation cycle.
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Affiliation(s)
- Chandana S Bhat
- Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - N Sanjeeva Reddy
- Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Radha Vembu
- Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Monna Pandurangi
- Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Revzin MV, Pellerito JS, Moshiri M, Katz DS, Nezami N, Kennedy A. Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know. Radiographics 2021; 41:1819-1838. [PMID: 34597234 DOI: 10.1148/rg.2021210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - John S Pellerito
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Nariman Nezami
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
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Tang S, Zhou Q, Zhang Y, Chen L, Yu X, Zhang Y, Qi Z, Xia Y, Huang Y. Ultrasound Measured Depth of Pelvic Free Fluid Correlates Well with Blood Loss Volume in Patients with Ectopic Pregnancy. Emerg Med Int 2020; 2020:8874581. [PMID: 33376608 DOI: 10.1155/2020/8874581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/10/2020] [Accepted: 11/28/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose The ultrasonic finding of pelvic free fluid which suggests the possibility of internal haemorrhage helps the determination of the severity of patients. Methods We conducted a retrospective study investigating ultrasonic measurements and haemorrhage volumes in patients having an ectopic pregnancy in a single centre from January 2013 to November 2016. The logistic regression model was used to establish the prediction model for haemorrhage volumes. The diagnostic accuracy was evaluated by area under ROC curve (AUC) analysis. We employed 800 ml as the cut-off point of the haemorrhage and further set it to 1000 ml and 1200 ml in the sensitivity analysis. Results The mean pelvic free fluid depths measured by TVS and TAS were 4.45 ± 2.15 cm and 4.45 ± 2.56 cm in the haemorrhage ≥800 ml group, while they were 2.48 ± 1.51 cm and 2.55 ± 1.19 cm in <800 ml group. AUCs and the corresponding cut-off points were 0.741 (95% CI 0.677 to 0.804) and 0.118 when predicted by the standardised depths of TVS and TAS, 0.784 (95% CI 0.696–0.872) and 2.95 cm by the raw depths of TVS, and 0.748 (95% CI 0.665–0.831) and 3.35 cm by the raw depths of TAS. Conclusions The depth of pelvic free fluid measured by TVS and TAS can be used to predict blood loss volume in patients having an ectopic pregnancy. TVS may perform better than TAS.
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Revzin MV, Moshiri M, Katz DS, Pellerito JS, Mankowski Gettle L, Menias CO. Imaging Evaluation of Fallopian Tubes and Related Disease: A Primer for Radiologists. Radiographics 2020; 40:1473-1501. [DOI: 10.1148/rg.2020200051] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Interstitial or cornual implantation of the blastocyst is rare, accounting for 2% to 3% of ectopic pregnancies, being considered not viable. The important complications of interstitial pregnancy are uterine rupture and massive bleeding, which usually occur before 12 weeks of pregnancy. The authors report a case of a 36-year-old woman with complaints of transvaginal bleeding and abdominal pain associated with amenorrhea for seven weeks and positive beta-human chorionic gonadotropin (HCG). Transvaginal ultrasound and exploratory laparotomy were performed, confirming the diagnosis of interstitial ectopic pregnancy. The patient underwent a salpingectomy and cornual resection on the left, evolving with clinical improvement and hospital discharge.
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Affiliation(s)
| | | | | | | | - Rosenildo de Sousa Figueiredo
- Obstetrics and Gynecology, Santa Casa de Misericórdia Hospital, Sobral, BRA.,Obstetrics and Gynecology, Sao Camilo Hospital, Tiangua, BRA
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Abstract
Tubal pregnancy represents an entity that every gynecologist will encounter during professional life. Because of the high prevalence among the pregnant population, standardized protocols are needed in order to choose the optimal strategy for each case. Accurate ultrasound pictures are supporting a more precise diagnosis of ectopic tubal pregnancy, the evolution of which should be closely monitored in follow-up with serial β-hCG values. Laparoscopy, intramuscular methotrexate, and active expectant management are all involved, however, tailoring the best treatment to the patient's needs is the challenge to focus on. This manuscript describes how in routinary practice an evidence-based diagnostic process should be the key factor to go for the best possible management. When possible, a longsighted less invasive approach should be preferred, aiming to preserve the patient's fertility for years to come. An optimal choice of the management should involve the patient or the couple in the decision-making process to reach the ultimate goal of compliance.
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Affiliation(s)
- Lorenzo Sabbioni
- Local Health Authority of Reggio Emilia, Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Italy
| | - Emanuela Carossino
- Local Health Authority of Reggio Emilia, Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Italy
| | - Filiberto Maria Severi
- Division of Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Stefano Luisi
- Division of Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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Abstract
Ultrasound is the imaging study of choice for detection and full characterization of early pregnancies based on its accuracy, low cost, safety profile, and abundant availability. This article reviews the goals and utility of first-trimester ultrasound in gestation localization, viability determination, and abnormal pregnancies, including ectopic implantation, retained products, and molar pregnancy.
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Affiliation(s)
- Peter S Wang
- Department of Radiology, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA.
| | - Shuchi K Rodgers
- Department of Radiology, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA
| | - Mindy M Horrow
- Department of Radiology, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA
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Nadim B, Lu C, Infante F, Reid S, Condous G. Relationship Between Ultrasonographic and Biochemical Markers of Tubal Ectopic Pregnancy and Success of Subsequent Management. J Ultrasound Med 2018; 37:2899-2907. [PMID: 29675930 DOI: 10.1002/jum.14652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To determine whether there is an association between morphologic types of tubal ectopic pregnancy (EP), 0-hour human chorionic gonadotropin (hCG) levels, and subsequent management success. METHODS We conducted a prospective study (November 2006-December 2015). Women had a diagnosis of EP by transvaginal ultrasonography if they had an inhomogeneous mass adjacent to the ovary and moving separately from it ("blob" sign), a mass with a hyperechoic ring around the gestational sac ("bagel" sign), or a gestational sac with an embryonic pole with or without a yolk sac with or without cardiac activity. The morphologic type, EP size, and 0-hour hCG level were analyzed. A multivariate analysis determined any correlation between these variables and nonsurgical management success. RESULTS A total of 7350 consecutive women underwent transvaginal ultrasonography, of whom 301 (4.2%) had a diagnosis of tubal EP; 181 (60.1%) had the blob sign; 90 (29.9%) had the bagel sign; and 23 (7.6%) were noted to have an embryo (14 viable and 9 nonviable). Eighty-three of 301(27.5%) women had expectant management; 67 of 301(22.2%) were given methotrexate; and 151 of 301 (50%) had surgery. Success rates for the groups were 77%, 75%, and 100%, respectively. No difference between the morphologic type and success rate of treatment was noted. Although there was a significant correlation between the EP mass size and 0-hour hCG level, the mass size itself was not correlated with the success rate of either medical or expectant management. Overall higher 0-hour hCG levels were associated with management failure. In the expectant group, median hCG level for failure was 589 IU/L versus 366 IU/L for success, whereas in the medical group, the median for failure was 1244 IU/L versus 7629 IU/L for success. CONCLUSIONS There is no significant correlation between the morphologic type and size of EP with a nonsurgical management outcome. A likely successful outcome is related to a lower level of serum hCG at presentation.
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Affiliation(s)
- Batool Nadim
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Chuan Lu
- Department of Computer Sciences, Aberystwyth University, Aberystwyth, Wales
| | - Fernando Infante
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Shannon Reid
- Department of Obstetrics and Gynecology Wollongong Hospital, Wollongong, New South Wales, Australia
| | - George Condous
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
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AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations. J Ultrasound Med 2018; 37:E13-24. [PMID: 30308091 DOI: 10.1002/jum.14831] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
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Abstract
There is considerable lack of clarity on the medical facts surrounding management of ectopic pregnancy. In particular, it is not widely appreciated that by the time an ectopic pregnancy is diagnosed, in most cases, there is no viable fetus (i.e., the fetus has already died). Moreover, there is very little ethical guidance from the medical profession regarding the emotionally difficult decision to terminate a wanted pregnancy when the life of the mother is at risk. The best articulated positions on this topic come from religious groups, based on the principle of double effect. Yet the application of this reasoning to termination of an ectopic pregnancy is inconsistent with the medical facts in many cases. To resolve these inconsistencies, while still providing a robust ethical context for resolving such difficult situations, we propose clear guidelines for determining when a viable fetus is present in ectopic pregnancy and clarify the moral object in ectopic pregnancy management. Summary: This paper explores the ethical framework for clinical decision making in the case of ectopic pregnancies. Focusing on the disordered union of mother and unborn child clarifies the object and purpose of the actions used to separate the mother and fetus in order to save the life of both, or at least one. Since over 90% of tubal ectopic pregnancies present as embryos who have already died, these cases present no ethical dilemma. This paper proposes a modification of currently used criteria for determining the viability of ectopic pregnancies and calls for further research.
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Affiliation(s)
- Maureen L Condic
- Department of Neurobiology and Anatomy, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Donna Harrison
- American Association of Pro-Life Obstetricians and Gynecologists, Eau Claire, MI, USA
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Brown DL, Packard A, Maturen KE, Deshmukh SP, Dudiak KM, Henrichsen TL, Meyer BJ, Poder L, Sadowski EA, Shipp TD, Simpson L, Weber TM, Zelop CM, Glanc P. ACR Appropriateness Criteria ® First Trimester Vaginal Bleeding. J Am Coll Radiol 2018; 15:S69-S77. [DOI: 10.1016/j.jacr.2018.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/27/2022]
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17
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Zamané H, Yameogo B, Kain PD, Kaboré FGX, Sawadogo YA, Kiemtoré S, Kaboré SY, Thiéba BB. Bilateral Tubal Pregnancy without Known Risk Factor. Case Rep Obstet Gynecol 2017; 2017:4356036. [PMID: 29181210 DOI: 10.1155/2017/4356036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/13/2017] [Indexed: 11/17/2022] Open
Abstract
Spontaneous bilateral ectopic gestation is very rare. The authors report a case diagnosed and taken care of at Yalgado Ouedraogo Teaching Hospital, Ouagadougou. It was a 30-year-old patient with no known pathological history. She had presented at the obstetric emergencies with a state of hypovolemic shock by haemoperitoneum with digestive disorders, pelvic pain, vaginal bleeding, and a mention of delayed menstruation. The ultrasound coupled with the urinary immunological pregnancy test confirmed the diagnosis of ruptured ectopic pregnancy and a bilateral form was suspected. A laparotomy in emergency confirmed the diagnosis of bilateral ectopic gestation with a right ampullary unruptured pregnancy and a left isthmic ruptured gestation. A bilateral salpingectomy was performed and counseling was made for the use of medical help of procreation in case of future need of pregnancy.
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18
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Aydoğmuş S, Aydoğmuş H, Gençdal S, Kelekçi S. Density of tubal ring vascularization: A new marker for prediction of success of medical treatment in tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2017; 217:113-118. [PMID: 28888180 DOI: 10.1016/j.ejogrb.2017.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 07/19/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The diagnosis of ectopic pregnancy has been facilitated especially by the use of Doppler ultrasonography. In previous studies the presence of peri-trophoblastic blood flow by Doppler ultrasound and the detection of a low-resistance, high-velocity flow pattern were defined as specific signs for trophoblastic tissue. The aim of this study was to evaluate the efficacy of Doppler ultrasonography in the prediction of treatment success in tubal pregnancies being treated with single dose conservative methotrexate. STUDY DESIGN A total of 104 patients with non-ruptured ectopic pregnancy who were hemodynamically stable and eligible for methotrexate treatment were included in the study. The spectral wave form of the mass was classified according to the vascularization density by Power Doppler. It was defined as Grade 1, 2 and 3, respectively. All patients received a single 50mg/m2 dose of systemic methotrexate. Serum β-hCG levels were measured on the 4th and 7th days of treatment. The treatment was considered unsuccessful in patients without a decrease of 15% or more in the serum β-hCG levels between days 0 and 7. RESULTS Twenty-four patients with grade I vascularity, 11 patients with grade II vascularity and 13 patients with grade III vascularity were referred as Group I, II and III, respectively, according to the degree of adnexal vascularity assessed by Doppler ultrasonography. Overall success rate of MTX treatment was found to be 72.9%. The response rates to systemic MTX treatment in cases with Grade I, II and III ectopic pregnancy mass vascularization were found to be 58.3%, 81.8% and 92.3%, respectively. Comparison of the groups' treatment responses revealed a linear-by-linear correlation with the Chi-square test. Increased vascularization grade of ectopic pregnancy was associated with a higher likelihood of responding to MTX treatment. CONCLUSIONS Detection of the vascularization grade with Doppler ultrasound could be considered a remarkable parameter in predicting treatment success considering its ease of utilization and low cost.
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Affiliation(s)
- Serpil Aydoğmuş
- İzmir Katip Çelebi University, School of Medicine Department of Obstetrics and Gynecology, İzmir, Turkey; İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey.
| | - Hüseyin Aydoğmuş
- İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
| | - Servet Gençdal
- İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
| | - Sefa Kelekçi
- İzmir Katip Çelebi University, School of Medicine Department of Obstetrics and Gynecology, İzmir, Turkey; İzmir Katip Çelebi University, Atatürk Research and Traininng Hospital, İzmir, Turkey
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19
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Abstract
Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound. In these situations, the primary role of pelvic ultrasound is to differentiate an ectopic pregnancy from either a normal or abnormal intrauterine pregnancy. While an accurately performed and interpreted pelvic ultrasound results in rapid diagnosis and management, numerous diagnostic pitfalls can lead to negative outcomes. Therefore, familiarity with the appropriate laboratory tests, sonographic technique, and imaging features of ectopic pregnancy is essential for all radiologists. We present a review of ectopic pregnancy cases from our institution with attention to common pitfalls and troubleshooting tips for physicians who perform and interpret pelvic ultrasounds. We also present recently published literature to aid in the management of first trimester pregnancy.
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20
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Nadim B, Condous G. Ultrasound features of tubal ectopic pregnancy. Australas J Ultrasound Med 2017; 20:3-4. [DOI: 10.1002/ajum.12043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Batool Nadim
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit Sydney Medical School Nepean University of Sydney Nepean Hospital Sydney New South Wales Australia
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit Sydney Medical School Nepean University of Sydney Nepean Hospital Sydney New South Wales Australia
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Taran FA, Kagan KO, Hübner M, Hoopmann M, Wallwiener D, Brucker S. The Diagnosis and Treatment of Ectopic Pregnancy. Dtsch Arztebl Int 2016; 112:693-703; quiz 704-5. [PMID: 26554319 DOI: 10.3238/arztebl.2015.0693] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
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.
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Yamada Y, Ohira S, Yamazaki T, Shiozawa T. Ectopic Molar Pregnancy: Diagnostic Efficacy of Magnetic Resonance Imaging and Review of the Literature. Case Rep Obstet Gynecol. 2016;2016:7618631. [PMID: 27648323 PMCID: PMC5014949 DOI: 10.1155/2016/7618631] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/07/2016] [Indexed: 02/07/2023] Open
Abstract
Ectopic molar pregnancy is extremely rare, and preoperative diagnosis is difficult. Our literature search found only one report of molar pregnancy diagnosed preoperatively. Moreover, there is no English literature depicting magnetic resonance image (MRI) findings of ectopic molar pregnancy. We report a case of ectopic molar pregnancy preoperatively diagnosed using MRI. A literature review of 31 cases of ectopic molar pregnancy demonstrated that lesions have been found in the fallopian tube (19 cases, 61%), ovary (5 cases, 16%), cornu (3 cases, 10%), peritoneum (2 cases, 6%), uterine cervix (1 case, 3%), and cesarean scar (1 case, 3%). Abdominal pain and abnormal vaginal bleeding were reported in 70% and 61% of the patients, respectively. Twenty-one cases (67%) presented with rupture and hemoperitoneum. All patients underwent surgical resection or dilatation and curettage. Methotrexate therapy was performed in one case because residual trophoblastic tissue was suspected. A second operation was performed in one case of ovarian molar pregnancy because serum hCG levels increased again after primary focal ovarian resection. No patients developed metastatic disease or relapsed. These findings suggest the prognosis of ectopic molar pregnancy to be favorable.
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23
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Abstract
Sonography is the imaging modality of choice to evaluate suspected intrauterine and extrauterine pregnancies. Determining the anatomic location of an ectopic pregnancy can be challenging, particularly when the ectopic is located external to the fallopian tube. Ovarian ectopic pregnancy is one of the rarest forms of nontubal ectopics. This report documents one such uncommon case of ovarian pregnancy in a woman presenting with light vaginal bleeding in early pregnancy, with subsequent rupture and laparotomy. Histopathologic analysis confirmed the diagnosis of ovarian ectopic pregnancy.
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Hoffmann S, Abele H, Bachmann C. Spontaneous Bilateral Tubal Ectopic Pregnancy: Incidental Finding During Laparoscopy - Brief Report and Review of Literature. Geburtshilfe Frauenheilkd 2016; 76:413-416. [PMID: 27134298 DOI: 10.1055/s-0041-110394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: Bilateral tubal ectopic pregnancies are rare; the reported incidence is only 1 in 200 000 pregnancies. Detecting bilateral tubal ectopic pregnancy is urgent because of the associated morbidity and mortality. The appropriate fertility-preserving surgery must also be considered, as preservation of both tubes is presumed to offer better fertility prospects. Case Report: A 39-year-old gravida 2, para 1 presented with vaginal bleeding at 8 + 4 weeks of gestation. An approximately 18 mm adnexal mass in the right fallopian tube was detected on ultrasound. Laparoscopy was performed because ectopic pregnancy was suspected. This suspicion was confirmed during laparoscopy; the right fallopian tube was found to contain a mass measuring 20 mm in the isthmic part. Ultrasound of the left fallopian tube also showed a mass in the ampullary region (diameter: 10 mm), also suspicious for ectopic pregnancy. Bilateral salpingotomy was performed laparoscopically. Pathological examination confirmed the diagnosis. Conclusions for Practice: Although ectopic tubal pregnancy is seen more often after assisted reproductive techniques, bilateral spontaneous ectopic pregnancies must also be considered in other cases. Laparoscopic surgery is effective to confirm the diagnosis and treat heterotopic pregnancies. Further studies will be needed to confirm whether unilateral or bilateral conservative fertility-preserving surgery is more appropriate.
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Affiliation(s)
- S Hoffmann
- Department of Obstetrics and Gynecology, Tübingen University Hospital, Tübingen
| | - H Abele
- Department of Obstetrics and Gynecology, Tübingen University Hospital, Tübingen
| | - C Bachmann
- Department of Obstetrics and Gynecology, Tübingen University Hospital, Tübingen
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25
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Polat İ, Ekiz A, Atis A, Ozkose B, Ustun B, Gedikbasi A. Advanced Tubal Ectopic Pregnancy with Tubal Torsion. J Gynecol Surg 2015. [DOI: 10.1089/gyn.2015.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- İbrahim Polat
- Department of Feto-Maternal Medicine, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey
| | - Ali Ekiz
- Department of Feto-Maternal Medicine, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey
| | - Alev Atis
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Burak Ozkose
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Batuhan Ustun
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ali Gedikbasi
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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