Efficacy and safety of a clinical protocol for expectant management of selected women diagnosed with a tubal ectopic pregnancy.

OBJECTIVE: To validate the efficacy and safety of our clinical protocol for expectant management of selected women diagnosed with tubal ectopic pregnancy. METHODS: This was a prospective observational study carried out in the early pregnancy unit of a London inner-city university teaching hospital from 1(st) January 2008 to 31(st) May 2011. All women presenting with suspected early pregnancy complications were assessed clinically and by transvaginal ultrasound. Those with a conclusive ultrasound diagnosis of tubal ectopic pregnancy were selected for either surgical or expectant management. Selection criteria for expectant management were clinical stability with no or minimal abdominal pain, no evidence of significant hemoperitoneum on ultrasound scan, ectopic pregnancy measuring < 30 mm in mean diameter with no evidence of embryonic cardiac activity, serum ß-human chorionic gonadotropin (ß-hCG) < 1500 IU/L and the woman's consent. All women selected for expectant management were followed up as outpatients until the ectopic pregnancy regressed spontaneously (resolution of clinical symptoms, serum ß-hCG < 20 IU/L/negative urine pregnancy test) or surgical intervention was required. We recorded the rate of interventions, complications and length of follow-up. RESULTS: During the study period 339/11 520 (2.9% (95% CI, 2.59-3.21%)) women were diagnosed with tubal ectopic pregnancy. Six women opted to participate in an ongoing randomized controlled trial and were excluded from further analysis. One hundred and sixty-five (49.5% (95% CI, 44.2-55.0%)) of the 333 remaining women met the criteria for expectant management; 146/333 (43.8% (95% CI, 38.5-49.1%)) of them opted for expectant management and 104/333 (31.2% (95% CI, 26.2-36.2%)) of all tubal ectopics resolved without requiring any intervention. All women with failed expectant management were treated by laparoscopic salpingectomy/salpingotomy and none of them required a blood transfusion. CONCLUSION: Our clinical protocol for expectant management of tubal ectopic pregnancies eliminates the need for medical or surgical treatment in more than a third of women diagnosed with tubal ectopic pregnancy with a minimum risk of adverse outcome.

Inter- and intraobserver variability in three-dimensional ultrasound assessment of the endometrial-myometrial junction and factors affecting its visualization.

OBJECTIVE: To assess the inter- and intraobserver variability of three-dimensional (3D) ultrasound assessment of the endometrial-myometrial junction (EMJ), and to assess demographic and physiological factors that affect the quality of its imaging. METHODS: Women attending our gynecology clinic, who were deemed to have normal uteri on transvaginal ultrasound examination, were enrolled in this prospective study. They underwent 3D volume acquisition of the entire uterus in order to acquire a coronal view of the organ. Visualization of EMJs was classified as optimal, satisfactory or unsatisfactory. In order to assess the intra- and interobserver variabilities of the classification system, the volumes were classified by two independent observers on two separate occasions. The same classification system was then used to evaluate the EMJs of 101 women who were deemed to have normal uteri on transvaginal ultrasound examination. The results were correlated with age, parity, stage of cycle, menopausal status and endometrial thickness in order to assess whether any of these factors affect visualization of the EMJ. RESULTS: A total of 30 uterine volumes were examined in the first analysis. Both the inter- and intraobserver variability were good (kappa values of 0.77 and 0.83). Of the 101 EMJs assessed in the second analysis, 47 were classified as optimal, 42 as satisfactory and 12 as unsatisfactory. Endometrial thickness was positively associated with EMJ visualization and parity was negatively associated with EMJ visualization. CONCLUSIONS: Assessment of EMJ visualization has both good inter- and intraobserver variability in women with normal uteri. Parity and endometrial thickness have contrasting, statistically significant, effects on visualization of the EMJ.

Pentamidine isethionate in the treatment of Pneumocystis carinii pneumonia.

The chemistry, antiprotozoal activity, pharmacology, clinical efficacy, adverse effects, dosage, administration, and hospital formulary considerations of pentamidine isethionate are reviewed. Pentamidine, an aromatic diamidine, has been used since the 1940s to treat a variety of protozoal infections. It is now most commonly administered in the treatment of Pneumocystis carinii pneumonia (PCP). It is generally not metabolized, and it is stored or bound to tissue and excreted slowly as the parent compound. Pentamidine is clearly effective in the treatment of PCP; however, the high incidence of adverse reactions associated with the drug led to the use of trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line agent for PCP. Recent studies have reported a high incidence of adverse reactions, including leukopenia and hepatotoxicity, associated with the use of TMP-SMX therapy for PCP in patients with the acquired immunodeficiency syndrome (AIDS). The severity and frequency of these reactions suggest a possible new role for pentamidine in patients with AIDS who have PCP. The recommended intramuscular and intravenous dosage of pentamidine isethionate for adults and children is 4 mg/kg/day for 14 days. Intramuscular administration is recommended; however, intravenous administration is a safe alternative if the dose is infused over a 60-minute period. Pentamidine isethionate has specific application in the treatment of PCP as a second-line agent reserved for patients who cannot tolerate TMP-SMX.