Hemorrhagic Shock in Primary Hepatic Pregnancy: A Diagnostic and Surgical Challenge

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

In recent years, ultrasound has become an essential tool in the assessment of women with suspected early pregnancy complications1. A large number of studies has already been published, describing the value of ultrasound in the diagnosis of ectopic pregnancy2,3. So, why write yet another review on this topic? We run a busy Early Pregnancy Unit in the area with the highest prevalence of ectopic pregnancy in the UK, which also receives many referrals from other hospitals of women with an uncertain diagnosis of ectopic pregnancy. The most interesting fact that we have learned over the years is that the majority of women referred with suspected ectopic pregnancies in fact had intrauterine ones that were either missed on ultrasound examination or misinterpreted as ectopics. This may sound surprising to many, as ultrasound diagnosis of intrauterine pregnancy is considered to be relatively simple and accurate. In many cases, ultrasound examination failed to identify a small amount of retained products of conception, due in part to inconsistencies in the sonographic diagnosis of incomplete miscarriage; this is often based on the use of arbitrary cut-off levels for endometrial thickness4. In other cases, however, sonographers were unable to decide whether a visible gestational sac represented an intrauterine or an ectopic pregnancy. In some cases with uncertain diagnosis, women had already received medical treatment with methotrexate prior to referral, leading to the loss of wanted normal intrauterine pregnancies. Another common problem is difficulty in differentiating between the various types of ectopic pregnancy. An accurate differential diagnosis is important in ectopics, as the management often differs depending on the type and exact location of the pregnancy. The purpose of this review is to summarize the sonographic criteria for the diagnosis of both intrauterine and ectopic pregnancies and to describe the principles of differential diagnosis of various types of ectopic pregnancy. We will not cover management of pregnancies of unknown location, as this issue has been covered extensively in recent publications5.

Early pregnancy failure: beware of the pitfalls of modern management

The diagnosis of ectopic pregnancy has undergone a major evolution in the past two decades. The introduction of sensitive β subunit human chorionic gonadotropin (β-hCG) assays and high resolution transvaginal sonography has enabled precise and early diagnosis of ectopic pregnancy before the development of critical signs and symptoms. Historically, clinicians managed ectopic pregnancy by excision via laparotomy. The suspicion for ectopic pregnancy resulting from the diagnostic work-up had to be strong enough to justify performing a major operation. The desire for conservative management of ectopic pregnancy and oviduct preservation made the diagnosis of unruptured gestational mass essential. The introduction of laparoscopy gave the clinician a powerful tool that enabled the making of an accurate diagnosis without a laparotomy skin incision. Later, the development of operative laparoscopy added a treatment ability to this diagnostic procedure. With the recent advent of medical treatment for ectopic pregnancy, an accurate and early diagnosis of ectopic pregnancy has become even more important. Although a surgical approach gives the clinician an opportunity to confirm the diagnosis, the medical therapy does not provide this verification, and, therefore, the diagnostic process must be thorough. In the past, many patients who were taken to the operating room with a diagnosis of presumptive ectopic pregnancy were found to have other benign conditions mimicking an ectopic pregnancy and frequently not requiring surgical treatment.1 A modern and more precise diagnostic process may limit or even eliminate such unnecessary surgical procedures. Thanks to a more reliable and earlier diagnosis of ectopic pregnancy, the initial presentation of a woman with this condition has changed during the recent years. Fewer patients develop acute abdomen and hypovolemia resulting from a ruptured and acutely bleeding ectopic implantation site. More prompt diagnosis and earlier intervention has led to a dramatic decrease in mortality from ectopic pregnancy. The population of women at high risk for developing ectopic pregnancy can be identified and prospectively screened for the location of implantation site early after conception.2 The advancement in the field of assisted reproductive technology (ART) has brought some new challenges to the diagnosis of ectopic pregnancy. Multiple implantations resulting from the transferring of multiple embryos obtained through fertilization in vitro may lead to more frequent heterotopic pregnancies (1% of all pregnancies resulting from in vitro fertilization), which are rare in spontaneous, unstimulated reproductive cycles (1:5,000 pregnancies). The natural history of ectopic pregnancy may vary. In some cases of trophoblast in regression, an early ectopic pregnancy may be in the process of spontaneous resolution, and no intervention is necessary. Other women who may be asymptomatic and clinically stable with no signs of intra-abdominal bleeding and no apparent adnexal mass may experience a sudden rupture of a small gestational extra-uterine mass and quickly develop hypovolemic shock. These different dynamics in the development of an ectopic pregnancy may confuse the clinician, who needs to remain cautious and critical during the diagnostic process. Conservative surgical management of ectopic pregnancy as well as medical therapy may not eradicate the trophoblastic tissue entirely. The remaining trophoblast may preserve its viability and continue to grow, leading to persistent ectopic pregnancy. Although the incidence of persistent ectopic pregnancy is low, ranging from 2-20% of conservatively treated women, it may result in sudden hemorrhage and tubal rupture in 24% of the cases.3

Pipelle endometrial biopsy in the diagnosis of ectopic pregnancy

Recurrent ectopic pregnancy is defined as the occurrence of more than one extrauterine implantation of a fertilized ovum. Ectopic pregnancy arises when a fertilized egg fails to implant within the endometrial cavity and instead attaches to an alternative site such as the fallopian tube, ovary, or peritoneal cavity. In this report, a rare case of recurrent ovarian ectopic pregnancy in a 31-year-old patient at six weeks’ gestation is presented. The aim of this study was to highlight the clinical presentation, diagnostic challenges, and management considerations associated with recurrent ovarian ectopic pregnancy. The patient was admitted to the emergency maternal unit with severe abdominal pain. A previous history of ectopic pregnancy raised the suspicion of recurrence. The diagnosis of ectopic pregnancy was established, and the patient underwent emergency exploratory laparotomy. During the procedure, the gestational sac was identified on the surface of the right ovary. Postoperatively, the patient required blood transfusion and supportive management, and was discharged in stable condition after several days of hospitalization. Ovarian ectopic pregnancy is an uncommon but serious condition. Early diagnosis, ideally with high-resolution ultrasonography, is essential to prevent life-threatening complications such as rupture, massive intra-abdominal hemorrhage, hemorrhagic shock, and maternal mortality. This case highlights the importance for clinicians of recognizing the possibility of recurrence in patients with a prior history of ectopic pregnancy and ensuring vigilant follow-up and timely intervention.

1060: Ectopic pregnancy

In this era of evidence-based medicine, when we read a meta-analysis, we expect to glean information that will be clinically useful. Indeed, before embarking on a meta-analysis, it is important for the researchers to understand the clinical importance of their topic and to include relevant articles in support of their research strategy. Thus, we were surprised by the description of the recent meta-analysis, ‘Accuracy of first-trimester ultrasound in diagnosis of tubal ectopic pregnancy in the absence of an obvious extrauterine embryo: systematic review and meta-analysis’1. The meta-analysis itself is well-described and follows guidelines appropriately; however, the authors never state why a review was needed, and what the current question is that needs to be answered. If a meta-analysis is to be helpful in changing care, the studies being assessed need to reflect the current standard of care. The vast majority of the articles reviewed were over 20 years old. One must consider that if there was clinical concern about the best method for imaging a diagnosis as common as ectopic pregnancy, there would be more recent accuracy studies. As the authors state, ‘The introduction of high-resolution transvaginal ultrasound has revolutionized the diagnosis of ectopic pregnancy’; why, then, did they include in their review some articles that used only the transabdominal technique? In the 1980s we did not have transvaginal scanning, and thus articles on sonographic diagnosis of ectopic pregnancy depended on transabdominal scanning alone. Even when transvaginal scanning became available, the frequency of the transducers was not as high as it is today. Indeed, one of the reasons for the increased incidence of ectopic pregnancy is felt to be the improvements in imaging technology. In the current era, pregnant women without visualization of an intrauterine pregnancy are scanned with transvaginal ultrasound. Transabdominal scanning alone is not standard of care, and has not been for decades. The authors did identify whether studies used transabdominal or transvaginal scanning during data extraction; it is somewhat disappointing that they did not take the extra step of performing subgroup analysis of those that used the transvaginal technique, since these would be the most indicative of present-day standard of care. Of similar concern is the analysis of criteria for diagnosis, such as the sole finding of free fluid or the sole finding of an empty uterus. These are not standard of care for diagnosis of ectopic pregnancy. While there is no doubt that the conclusions of the meta-analysis – that, based on sonographic findings, we can rule in ectopic pregnancy, but we cannot exclude it – are correct, one must wonder why old articles, using techniques no longer in use today, were needed in order to arrive at a conclusion that is already well-established in clinical care. D. Levine*† and M. McInnes‡ †Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; ‡Department of Radiology, University of Ottawa, The Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada *Correspondence. (e-mail: [email protected])

hCG as a patient

204: Rate of Ectopic Pregnancy In Pregnant Patients With a First-Visit Beta-hcg Level of Less Than 1,500: A Three-Year Review

A 23-year-old female, gravida 2, para 1, at 9 weeks gestation presented to the emergency department with a 2-day history of right lower quadrant pain and light vaginal spotting. The patient had not undergone formal ultrasound during this pregnancy. The patient denied nausea, vomiting, migration of pain, anorexia, fever, dizziness, and syncope, and vital signs were normal. Examination revealed tenderness in the right adnexal region, but lacked any evidence of peritonitis, rebound, or guarding. Goal-directed bedside ultrasound performed by the treating emergency physicians while awaiting laboratory testing revealed a live 9-week right interstitial pregnancy (1, 2 and Video Clip S1, available as supporting information in the online version of this paper). Obstetrics was contacted immediately and arrangements were made to take the patient to surgery. Transabdominal sagittal view of interstitial pregnancy. The gestational sac is at the perimeter of the right edge of the uterus (Ut), and there is less than 5 mm of the myometrial mantle (seen as solid white line in image). Endovaginal sagittal view of interstitial pregnancy. The gestational sac is outside the endometrial echo of the uterus (Ut), and there is less than 5 mm of the myometrial mantle (seen as solid white line in image). EMS = endometrial stripe. Ectopic pregnancy occurs in 1.9% of reported pregnancies and is the leading cause of pregnancy-related death in the first trimester.1 Interstitial (or cornual) pregnancy is a rare type of ectopic pregnancy with an incidence of 0.7% to 4%; however, rupture occurs relatively early in pregnancy and is associated with severe hemorrhage and increased morbidity and mortality.1 Timor-Tritsch and colleagues2 proposed the following ultrasound criteria for diagnosis of interstitial pregnancy: “1) an empty uterine cavity; 2) a gestational sac located eccentrically and >1 cm from the most lateral wall of the uterine cavity; and 3) a thin (<5 mm) myometrial layer surrounding the gestational sac.” The supplemental video clip illustrates how goal-directed bedside ultrasound is a useful and noninvasive tool for the emergency physician in the diagnosis of ectopic pregnancy. Video Clip S1. Goal-directed bedside ultrasound. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Intramural ectopic pregnancy is a very rare diagnosis. Establishing a diagnosis is difficult and is often made intraoperatively. Demonstration of a live extrauterine gestation is the only specific sign of such a pregnancy. A small number of ectopic pregnancies are interstitial or cornual pregnancies. Rupture of an intramural ectopic pregnancy is a serious clinical complication. Diagnosis of this ectopic pregnancy can sometimes be made using 2-dimensional transvaginal ultrasound (TVS), but it may also require 3-dimensional TVS. We present the case of a 25-year-old gravida 0, para 0 woman with amenorrhea lasting 6(+5) weeks. Previous surgery included a right adnexectomy for torsion of a right dermoid cyst. The patient's serum hCG was elevated. TVS provided a detailed view of the endometrial cavity. The results of 2-dimensional TVS suggested the presence of an ectopic pregnancy. The sonogram showed a gestational sac with an embryonic pole and a yolk sac, which was separated from the endometrium. Use of 3-dimensional TVS demonstrated a live embryo in a gestational sac surrounded by myometrium below the right cornu lying outside the endometrium. This finding was confirmed by laparotomy and the conceptus was excised. The patient had an uneventful postoperative course and was discharged 7 days after surgery. In our case, the previous adnexectomy was an identifiable risk factor. Nonetheless, making a diagnosis of an intramural pregnancy was challenging. Suspicion may arise when sonography has revealed an intramural gestational sac.

Expectant management of a cornual pregnancy followed up by serial transvaginal color power Doppler angiography and serum beta human chorionic gonadotropin levels

Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience

We wanted to evaluate the utility of seven biochemical markers in the early diagnosis of ectopic pregnancy. Women with pain and bleeding suspicious for ectopic pregnancy were evaluated prospectively. Each woman had a transvaginal sonogram and serum determination of beta-human chorionic gonadotropin (beta-hCG), progesterone, estradiol (E2), creatine phosphokinase (CPK), CA-125, 17-hydroxyprogesterone, and androstenedione. The women were grouped in two ways, and there was considerable overlap between the two groups. One grouping included those with <45 days of amenorrhea, and the other included those whose beta-hCG was <2500 mIU/ml. Each marker was analyzed by univariate and multivariate logistic regression to see which could best distinguish ectopic pregnancies from nonectopic pregnancies. In the group of women with <45 days of amenorrhea, ectopic pregnancies were distinguished by a low progesterone and a high CPK. None of the other biochemical markers were significantly associated with ectopic pregnancy in the multivariate logistic regression analysis. A receiver operating characteristic (ROC) curve was constructed for the CPK/progesterone ratio. As an example of different cut points, a CPK/progesterone ratio >15 was 87% sensitive and 83% specific in the diagnosis of ectopic pregnancy. In the group of women with beta-hCG <2500 mIU/ml, the only biochemical marker found to be significantly associated with ectopic pregnancy was CPK. An ROC curve was constructed for CPK in this group. As an example of different cut points, a CPK >70 had a 78% sensitivity and 81% specificity in the diagnosis of ectopic pregnancy. We conclude that the CPK/progesterone ratio is helpful in those women with <45 days of amenorrhea, and serum CPK levels are helpful in women whose beta-hCG is <2500 mIU/ml. Although serum levels of CPK and the ratio of CPK/progesterone are the most helpful in making the diagnosis of early ectopic pregnancy, they are not good enough to be used alone in clinical practice.