Dopplersonographische Vitalitätskriterien bei klinisch stabiler Extrauteringravidität - eine Entscheidungshilfe für die Therapie

Abstract

The differentiation between viable ectopic pregnancies with trophoblastic activity and tubal abortions could be a therapeutic aid for the determination of an operative versus a conservative management. Since the typical sonographic picture of an ectopic pregnancy - an extrauterine gestational sac surrounded by an echogenic ring - corresponds histologically to the oedematous tube in combination with the trophoblast, good vascularisation within this structure should indicate the chorionic activity of the ectopic pregnancy and thereby its viability. In 34 patients with sonographically definitely confirmed ectopic pregnancy from the 6 th to 10 th week of gestation who presented with typical but not acute symptoms of an EP (bleeding disorders, positive pregnancy test together with an empty uterus in sonography, slight ache in the lower abdomen or sonographic proof of an ectopic pregnancy in private practice) we therefore examined this echogenic ring by transvaginal colour Doppler sonography (Acuson 128 XP/10, 5 Mhz transvaginal probe EV 519) in a prospective study. Subsequently 29 patients underwent laparoscopy or laparotomy where 16 tubes had to be removed partially or completely. The histological examination of the removed tissue was performed by haematoxyline-eosine staining as well as by immune histochemical methods (factor VIII-antibody, Dako, Heidelberg, FRG) to identify and precisely localise the vessels in the area of the ectopic pregnancy seen in the Doppler sonographic examination. In accordance with the increasing experience with this technique, five patients were treated by conservative methods (single i.v. administration of methotrexate, 30mg). Whereas viable ectopic pregnancies (n=11) exhibited a ring of vessel spots at the rim of this echogenic ring, there were only three or less weak vessel spots or even no vessel spots at all in tubal abortion (n=23). The Doppler sonographic findings could also be verified on histological examination; this correlation was statistically significant also after subtracting the five ectopic pregnancies with positive heart beat (p<0.01; Fisher's exact test). The major therapeutic problem especially of the conservative approach was the slow normalisation of the pregnancy hormone. Even if this is taken into account, Doppler sonography of the echogenic ring around the extrauterine gestational sac is nevertheless an additional help for counselling the clinically stable patient concerning further therapeutic procedures, since it is a fast and simple method for determining the viability of an ectopic pregnancy. It provides a certain independence of the laboratory concerning the determination of the pregnancy hormone and it correlates with the ensuing;histological examination.