Ectopic pregnancy: a single-center experience over ten years.

PURPOSE: The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality. METHODS: This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, ß-human chorionic gonadotropin (ß-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA). RESULTS: The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10- 5) that was diagnosed in the 7th gestational week. The only association found was between the ß-HCG level and LOS, with a linear regression ß coefficient of 0.01 and a P-value of 0.04. CONCLUSION: EP is a relatively common condition affecting approximately 1% of all pregnancies. ß-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

Subsequent Fertility in Women Treated for Caesarean Scar Pregnancy With Hysteroscopy: A 5-Year Follow-Up Descriptive Study in a Tertiary Hospital.

Objective: The outcomes of subsequent pregnancies and fertility in women with a history of caesarean scar pregnancy have not been well described. In this study, we followed up 149 women with a history of caesarean scar pregnancy and analysed the effect on their fertility. Methods: 149 women with a history of caesarean scar pregnancy were followed up for five years. Of them, 53 women had unprotected sexual intercourse attempting to become pregnant again. Data including clinical parameters and treatment options at the time of diagnosis of caesarean scar pregnancy, and the outcomes in subsequent pregnancy were collected. In addition, a questionnaire about the menstrual cycle after treatment was voluntarily completed by these women. Results: Of the 53 women, 46 (84%) women had a subsequent pregnancy, while seven (14%) women did not. There was no association between the clinical parameters in previous caesarean scar pregnancy or treatment and future fertility. From the questionnaire, there was no difference seen in the length of the menstrual cycle and menses between the two groups. However, a higher number of women with light menstrual bleeding were seen in women without a subsequent pregnancy (67%), compared with women who did (28%). In addition, six women (13%) who had a subsequent pregnancy experienced foetus death in the first trimester. Conclusion: We reported that 14% of women with a history of cesarean scar pregnancy did not have a subsequent pregnancy, after unprotected sexual intercourse for more than two years. Light menstrual bleeding after treatment may be associated with this adverse effect. Our findings need to be further investigated with large sample size.

The predictive value of endometrial thickness in 3117 fresh IVF/ICSI cycles for ectopic pregnancy.

OBJECTIVES: To evaluate the predictive value of endometrial thickness (EMT) during in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles for ectopic pregnancy (EP). METHODS: A total of 3068 patients with 3117 fresh IVF/ICSI cycles between January 2016 and February 2019 from the Reproductive Medicine Center of Sun Yat-Sen Memorial Hospital were included in this retrospective study. The patients were divided into an EP group (n = 92) and an intrauterine pregnancy (IUP) group (n = 3025). Multiple logistic regression analysis was conducted to evaluate the EP risk factors. Receiver operating characteristic (ROC) curves were used to evaluate the predictive value of the risk factors for EP and calculate the cutoff value of EMT for EP prediction. RESULTS: The incidence rate of EP was 2.95 % (92/3117). After adjustment for other factors in the logistic regression model, the incidence of EP decreased by 55 % with an EMT > 10 mm compared with an EMT ≤ 10 mm (odds ratio 0.450, 95 % confidence interval 0.296-0.684, P < 0.001). The EMT in the EP group was significantly thinner than that in the live birth (n = 2540) and spontaneous abortion (n = 485) groups (p < 0.017). The cutoff value of EMT for EP prediction was 10.65 mm, with a sensitivity of 59 % and a specificity of 63 %. CONCLUSION: A decreased risk of EP was found among the patients with an EMT > 10 mm prior to embryo transfer. A certain EMT is needed to reduce the incidence of EP.

Tubal factor infertility with prior ectopic pregnancy: a double whammy? A retrospective cohort study of 2,892 women.

OBJECTIVE: To investigate the impact of a history of previous naturally conceived tubal ectopic pregnancy (TEP) on subsequent IVF/intracytoplasmic sperm injection (ICSI) pregnancy and perinatal outcomes. DESIGN: Retrospective cohort study. SETTING: Reproductive medicine center in a tertiary hospital. PATIENT(S): A total of 2,892 women with tubal infertility undergoing the first fresh IVF/ICSI cycle. INTERVENTION(S): Women were stratified into three groups according to the type of previous naturally conceived pregnancy: TEP, intrauterine pregnancy (IUP), and no pregnancy. MAIN OUTCOMES MEASURE(S): Pregnancy and neonatal outcomes were analyzed for each cohort and stratified into the following categories based on female age: <30 years, 30-35 years, and ≥35 years. RESULT(S): Of the 2,892 patients with tubal factor infertility, 511 (17.7%) women had a history of TEP, 1,044 (36.1%) had prior IUP, and 1,337 (46.2%) had never been pregnant. Couples with an initial TEP tended to be younger and had experienced a shorter duration of infertility. Across the whole cohort, the optimal live birth rate decreased in older age groups. Live birth rates stratified by maternal age (<30, 30-35, ≥35 years) did not differ between the TEP group (59.9%, 53.7%, 45.5%) and the IUP (62.0%, 53.8%, 40.6%) and no pregnancy group (56.7%, 54.4%, 45.6%). This did not change after adjusting for confounders such as age and years of infertility. Previous treatment of TEP with salpingectomy, salpingostomy, or medical treatment did not significantly affect subsequent fertility outcomes. The rates of preterm and low birth weight after TEP were also not significantly higher than in women with a previous IUP. CONCLUSION(S): Fertility history, including previous TEP, does not influence the probability of live birth after IVF/ICSI in women with tubal factor infertility.

Roles of steroid hormones in oviductal function

The oviduct (known as the fallopian tube in humans) is the site for fertilization and pre-implantation embryo development. Female steroid hormones, estrogen and progesterone, are known to modulate the morphology and function of cells in the oviduct. In this review, we focus on the actions of estrogen and progesterone on secretory, ciliated, and muscle cell functions and morphologies during fertilization, pre-implantation embryo development, and embryo transport in humans, laboratory rodents and farm animals. We review some aspects of oviductal anatomy and histology and discuss current assisted reproductive technologies (ARTs) that bypass the oviduct and their effects on embryo quality. Lastly, we review the causes of alterations in secretory, ciliated, and muscle cell functions that could result in embryo transport defects.

The performances of serum activins and follistatin in the diagnosis of ectopic pregnancy: A prospective case-control study.

BACKGROUND: The diagnosis of ectopic pregnancy (EP) is challenging and 40-50% of patients are initially misdiagnosed. METHODS: This prospective case-control study measured activin-A, activin-B, activin-AB and follistatin for the diagnosis of EP, spontaneous abortion (SAB) and normal intrauterine pregnancy (IUP). Sera were collected from 120 women with symptoms suggesting early pregnancy failure and who were clinically diagnosed as IUP, SAB or EP (n = 40/group). The markers were measured by ELISA and their area under the curve (AUC), cut-off value, sensitivity and specificity were determined by receiver-operating characteristic curve. The results were compared with serum ß-human chorionic gonadotropin and progesterone. RESULTS: Activin-A and activin-B decreased significantly, while activin-AB and follistatin increased, in the EP and SAB groups than the IUP group. Activin-AB (AUC = 0.961) and progesterone (AUC = 0.973) were the best markers for EP and SAB, respectively. Activin-AB (≥61.5 pg/mL) showed 92.5% sensitivity, 85% specificity, 75.5% positive predictive value (PPV) and 95.8% negative predictive value (NPV) for EP. Progesterone (≤6.3 ng/mL) had 100% sensitivity, 86.2% specificity, 78.4% PPV and 100% NPV for SAB. CONCLUSIONS: Serum activins and follistatin were significantly altered with EP and activin-AB could be a promising marker for the diagnosis of EP.

Ultrasound in Early Pregnancy: Viability, Unknown Locations, and Ectopic Pregnancies.

Ultrasound is essential in the evaluation and management of pregnancies of unknown location. Differential diagnoses include early pregnancy loss, pregnancy of unknown location, and ectopic pregnancies. Both transabdominal and transvaginal routes should be available, in addition to physical examination, for complete evaluation. Diagnostic criteria for early pregnancy loss have expanded in recent years to ensure false positive results do not lead to inappropriate evacuation of desired pregnancies.

The effect of salpingectomy on the ovarian reserve and ovarian response in ectopic pregnancy: A systematic review and meta-analysis.

BACKGROUND: Salpingectomy is routinely performed in ectopic pregnancy (EP). However, the effect of the surgery on the ovarian reserve and ovarian response in EP patients is still uncertain and has not been systematically evaluated. Therefore, we conducted this meta-analysis to provide a comparison of the ovarian reserve and ovarian response between the pre-salpingectomy and post-salpingectomy in EP patients. METHODS: Pubmed, Embase, and Cochrane Library were searched for all relevant articles published up to December 2018. We retrieved the basic information and data of the included studies. The data was analyzed by Review Manager 5.3 software (Cochrane Collaboration, Oxford, UK). RESULTS: A total of 243 articles were extracted from the databases, and 7 studies were included in the meta-analysis. The ovarian reserve including anti-Mullerian hormone (inverse variance [IV] -0.7 [95% confidence interval [CI] -0.63, 0.49]), antral follicle count (IV 1.7 [95% CI -2.02, 5.42]) and basal follicle stimulating hormone (IV 0.02 [95% CI -0.63, 0.68]) was comparable between the pre-salpingectomy group and the post-salpingectomy group. The amount of gonadotropin was significantly higher in the post-salpingectomy group when compared with that in the pre-salpingectomy group (IV -212.65 [95% CI -383.59, -41.71]). There was no significant difference in the left parameters of the ovarian response including the duration of gonadotropin stimulation (IV -0.32 [95% CI -0.76, 0.12]), the estrogen level on the human chorionic gonadotropin triggering day (IV -4.12 [95% CI -236.27, -228.04]) and the number of retrieved oocytes (IV 0.35 [95% CI -0.76, 1.46]) between 2 groups. CONCLUSIONS: The current results suggest that salpingectomy has no negative effect on the ovarian reserve and ovarian response.

Ectopic pregnancy and outcomes of future intrauterine pregnancy.

OBJECTIVE: To provide information on the birth outcomes of future intrauterine pregnancies in women whose first pregnancy was ectopic. DESIGN: Population-based longitudinal cohort study. SETTING: All hospitals in Quebec, Canada, 1989-2013. PATIENT(S): Group surgically treated for an ectopic first pregnancy: 15,823 women; comparison group with an intrauterine first pregnancy: 1,101,748 women. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Repeat ectopic pregnancy, future delivery of a live infant, stillbirth, cesarean delivery, preterm birth, low birth weight, preeclampsia, gestational diabetes, and postpartum hemorrhage as well as other outcomes of pregnancy. RESULT(S): The overall prevalence of ectopic first pregnancy was 14.2 per 1,000 women, of whom 10% of women with an ectopic first pregnancy had a future ectopic. Regardless of age, women with ectopic first pregnancies had an increased risk of adverse birth outcomes at future intrauterine pregnancies, including 1.27 times the risk of preterm birth (95% confidence interval [CI], 1.18-1.37), 1.20 times the risk of low birth weight (95% CI, 1.10-1.31), 1.21 times the risk of placental abruption (95% CI, 1.04-1.41), and 1.45 times the risk of placenta previa (95% CI, 1.10-1.91). Older women with a prior ectopic pregnancy had particularly elevated risks of placental abruption (risk ratio 1.42; 95% CI, 1.16-1.69). CONCLUSION(S): Women with ectopic first pregnancies have an increased risk of adverse birth outcomes during subsequent intrauterine pregnancies. These women may benefit from closer clinical management in pregnancy to prevent adverse birth outcomes.

Cervical Ectopic Pregnancy: A Rare Site of Implantation.

BACKGROUND: Cervical ectopic pregnancies are rare, comprising < 1% of ectopic pregnancies, and life threatening if there is a delay in treatment or a misdiagnosis. CASE REPORT: This case report describes a presentation of cervical ectopic pregnancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report reviews nonsurgical and surgical treatment options for patients with cervical ectopic pregnancies.

Ovarian ectopic pregnancy.

A twenty-eight-year-old female patient during the second pregnancy, about 6 hbd (according to the date of the last menstrual period) from the spontaneous cycle, was directed to the local hospital because of suspected ectopic pregnancy with the location of the fallopian tube on the left side. She had no symptoms and vital parameters were in normal range. It was revealed that three years ago ectopic pregnancy of the right uterine tubule ended with right fallopian tube removal.

Risk factors for ectopic pregnancy in a population of Cameroonian women: A case-control study.

OBJECTIVE: To identify the risk factors for ectopic pregnancy (EP) in a population of Cameroonian women. SAMPLE AND METHODS: We performed a matched case-control study; 88 women with diagnosed EP (cases), and 176 women with first trimester intrauterine pregnancy (IUP) (controls), who underwent questionnaires. Odds Ratio (OR) and 95% confidence intervals (CIs) were calculated and adjusted for potential confounding factors via multivariate logistic regression analysis. RESULTS: Of the fifteen identified risk factors, 4 were independently associated with increased odds of EP: prior pelvic inflammatory disease (PID) (adjusted odds ratio [AOR] 13.18; 95% CI 6.19-27.42), followed by current use of levonorgestrel-only pills for emergency contraception (LNG-EC) (AOR 10.15; 95% CI 2.21-46.56), previous use of depot medroxyprogesterone acetate (DMPA) (AOR 3.01; 95% CI 1.04-8.69) and smoking at the time of conception (AOR 2.68; 95% CI 1.12-6.40). CONCLUSION: The present study confirms the wide variety of EP's risk factors. Moreover, some new findings including current use of LNG-EC, previous use of DMPA, smoking at the time of conception are noteworthy. Thus, in our limited resources country where prevention remains the cornerstone for reducing EP chances of occurrence, clinicians should do enough counselling, especially to women with known risk factors. The necessity to facilitate access to more equipment to enable early diagnosis of EP is very crucial and should be seriously considered, in order to reduce the burden of EP in Cameroonian women.

Massive hemorrhage from a unique old cesarean scar ectopic pregnancy with negative urine and serum ß-HCG: a rare case report.

Human chorionic gonadotropin (HCG) is an important indicator for the diagnosis of pregnancy. The authors report a unique case of cesarean scar ectopic pregnancy (CSEP) with negative urine and serum HCG levels, which was initially misdiagnosed as an intrauterine tumor despite the use of transvaginal ultrasound. Dilation and curettage was performed, which caused massive vaginal bleeding. Diagnostic hysteroscopy after uterine artery embolization and pathological examination of the surgical specimen confirmed the diagnosis of old CSEP. Postoperative follow-up showed that normal menstruation restarted 2 months later. This case reminds gynecologists and obstetricians the diagnosis of CSEP should be considered, especially when there is a mass at or near the surgical scar, regardless of the HCG level.

Analysis Of Two Years Cases Of Ectopic Pregnancy.

BACKGROUND: Ectopic pregnancy is the leading cause of pregnancy related deaths in the first trimester. The aim of this study was to evaluate the frequency of risk factors, clinical presentation, diagnostic methods and site of ectopic pregnancy. METHODS: This descriptive cross sectional study was conducted in Gynaecology and Obstetrical Unit-A of Ayub Teaching Hospital Abbottabad from 1st October 2013 to 31st October 2015. All women diagnosed with ectopic pregnancy were included in the study. A predesigned proforma was used to record the details about demographic features, risk factors, clinical features at presentation, diagnostic methods and site of ectopic pregnancy. RESULTS: Out of total 6675 patients admitted during the study period, 45 cases of ectopic pregnancy were diagnosed with frequency of ectopic pregnancy to be 0.65%. Mean age of the patients was 28.98±5.525. Majority of patients were primigravida14 (31.3%), 9 (20.0%) gravida 2, 5 (11.1%) gravida 3, 4 (8.8%) gravida 4, 7 (15.5%) gravida 5, 6 (13.3%) found grand multi out of total 45 ectopic pregnancies, 45% of the patients had no identifiable risk factors, however history of infertility 20 (22.22%), history of Pelvic inflammatory disease (PID) 10 (22.22%), previous ectopic 2 (4.44%) and previous abdominal pelvic surgery 3 (6.67%) were identified as common risk factors of 45 ectopic pregnancies. Out of total 45 sufferers 23 (51.11%) were clinically diagnosed, 20 (44.44%) through abdominal ultrasound and 2 (4.44%) through transvaginal ultrasound. The most frequent clinical presentation was amenorrhea 30 (66.67%) followed by abdominal pain 28 (62.22%), irregular vaginal bleeding 18 (40.00%), asymptomatic patients with routine ultrasound 18 (40.0%) and 10 (22.22%) presented in shock. Twenty-eight (62.2%) of the ectopic pregnancies were found in right sided fallopian tube and 17(37.8%) were found in left sided fallopian tube. The commonest site of ectopic pregnancy was ampulla 29 (64.44%) followed by 11 (24.44%) Isthmus, 4 (8.89%) fimbrial end and 1 (2.22%) were rudimentary horn of uterus out of total 45 ectopic pregnancies. Evidence of 32 (71.1%) patients with ruptured ectopic was recorded. Thirteen (28.9%) were unruptured ectopic. CONCLUSIONS: Amenorrhea and abdominal pain are the most consistent features of ectopic pregnancy.

Ovarian hyperstimulation syndrome following GnRH agonist trigger-think ectopic.

PURPOSE: This study aims to report a case of ovarian hyperstimulation syndrome (OHSS) following GnRH agonist trigger for final follicular maturation. METHODS: This study is a retrospective chart review. RESULTS: We report the first case of OHSS following GnRH agonist trigger for final follicular maturation and freeze-all, masking extrauterine pregnancy (EUP). The present case report elucidates the feasibility of stimulating and recruiting ovarian follicles yielding mature oocytes during early pregnancy and the ability of GnRH agonist to trigger final follicular maturation during pregnancy, in the presence of high progesterone and hCG levels. CONCLUSIONS: Since OHSS almost always develops after hCG administration or in early pregnancy, its occurrence following GnRH agonist trigger should alert physician to search for either an inadvertent administration of exogenous hCG, or the endogenous secretion of hCG by pregnancy, e.g. EUP, or as part of a paraneoplastic syndrome.

Sigmoid Microinvasion by an Ectopic Pregnancy.

BACKGROUND: Approximately 2.1% to 8.6% of all pregnancies after IVF with embryo transfer have been reported to be ectopic. In this report, we present a case of presumed intestinal microperforation caused by an ectopic pregnancy following IVF. CASE: A 29-year-old woman presented with rectal bleeding. She had previously been treated for an ectopic pregnancy for which she had received two doses of methotrexate. Colonoscopy and abdominal CT angiography were performed and showed that the ectopic pregnancy was attached to the sigmoid colon. Surgery was performed to remove the ectopic pregnancy. Because intestinal microperforations were suspected, the patient received intravenous antibiotic therapy during her hospitalization. CONCLUSION: In cases of intestinal bleeding, clinicians should consider the possibility of intestinal involvement of an ectopic pregnancy, even if the response to treatment for the ectopic pregnancy has been appropriate.

Reproductive outcomes following cesarean scar pregnancy - a case series and review of the literature.

OBJECTIVE: To assess the reproductive outcomes following cesarean scar pregnancy (CSP) in our center and review of published literature on CSP and subsequent reproductive issues. METHODS: Over a 3-year period, 28 cases of CSPs were diagnosed in our hospital. Follow up data of 22 cases were available which included the gestational age at diagnosis of CSP, treatments employed and outcomes of previous cesarean scar pregnancy. We also had details on subsequent fertility outcomes in these women, which included intervals between the previous CSP and subsequent pregnancy, maternal and neonatal outcomes of these subsequent pregnancies and mode of delivery. RESULTS: Eight women desired to conceive and amongst them, seven women manage to conceive spontaneously. There were five pregnancies delivered at term, two miscarriages and one recurrent CSP. One patient had placenta accreta diagnosed at cesarean section at term and had massive hemorrhage. The remaining 4 term pregnancies were delivered uneventfully by elective cesarean sections. The mean interval between the cesarean scar pregnancy and subsequent pregnancy was 24.6 months (range 9-48 months). One patient experienced secondary infertility and despite thorough investigations, no abnormalities were detected. One of the women who did not desire future fertility conceived spontaneously at 9 and 18 months respectively after one CSP and had induced abortions twice. There were 3 women who had uterine scar defect repaired, only 1 resulted in a live birth but had placenta accreta with a lower uterine segment defect and suffered from massive hemorrhage, one woman had a subsequent miscarriage with a diverticulum in the lower uterine segment, and one woman had unexplained secondary infertility. CONCLUSION: Most women were able to conceive following CSPs. Reproductive outcomes included normal intrauterine term pregnancy, miscarriage, recurrent CSP, and infertility. Placenta accreta, which could be misdiagnosed antenatally, was a serious complication in subsequent pregnancies. Diverticulum or defect in the lower uterine segment could happen after CSP. Repair of the uterine defect, following a CSP neither guaranteed the healing of the scar, nor the ability to ensure a safe pregnancy outcome. Appropriate counseling to women desiring fertility with a history of CSP is essential and once they conceive early referral to tertiary centers for follow up is pertinent.

Is there a difference in the behaviour and subsequent management of ectopic pregnancies seen at first scan compared to those ectopic pregnancies which commence as pregnancies of unknown location?

AIMS: The primary aim was to assess whether ectopic pregnancies (EPs) visualised on primary scan behave differently to EPs initially characterised as pregnancies of unknown location (PUL). The secondary aim was to assess whether the EP group is more likely to have surgical management compared to the PUL ectopic pregnancy group. MATERIALS AND METHODS: Prospective observational study. Consecutive first trimester women presenting from November 2006 to March 2012 underwent transvaginal ultrasound (TVS). Women diagnosed with an EP on TVS were divided into two groups: visualised EPs noted on the first TVS, and PULs which subsequently developed into EPs. Twenty-five historical, clinical, biochemical and ultrasonographic variables were collected. Different management strategies (expectant, medical, surgical) once an EP was confirmed on TVS were recorded. Univariate analysis was performed to compare differences between the two groups as well as rates for the three final management strategies. RESULTS: A total of 3341 consecutive women underwent TVS. On initial scan, 86.2% were classified as intrauterine pregnancy, 8.8% as PUL and 5.0% as EP (145 tubal/23 nontubal EPs). There were 194 tubal EPs in final analysis: 49 of 194 (25.3%) initially classified as PUL and 145 of 194 (74.7%) diagnosed as EP at primary TVS. When comparing the EP to the PUL EP group, the pain scores were 3.34 versus 1.91 (P-value < 0.001), the mean sac diameters were 35.2 versus 18.5 mm (P-value = 0.0327), and the volume of the EP masses were 8.21E+04 versus 1.40E+04 (P-value = 0.0341). Cumulative surgical intervention rate was significantly higher in EP compared to PUL EP group (P-value = 0.036). CONCLUSIONS: EPs seen at the first ultrasound scan appear to be more symptomatic, larger in diameter and volume compared to EPs which started as PULs. Cumulative surgical intervention rate was noted to be higher in this group with EP seen on ultrasound at the outset.

Pelvic inflammatory disease: diagnosis and treatment in the emergency department [digest].

Pelvic inflammatory disease is a common disease that is associated with significant complications including infertility, chronic pelvic pain, ruptured tubo-ovarian abscess, and ectopic pregnancy. The diagnosis may be delayed when the presentation has nonspecific signs and symptoms. Even when it is properly identified, pelvic inflammatory disease is often treated suboptimally. This review provides evidence-based recommendations for the diagnosis, treatment, disposition, and follow-up of patients with pelvic inflammatory disease. Arranging follow-up of patients within 48 to 72 hours and providing clear patient education are fundamental to ensuring good patient outcomes. Emerging issues, including new pathogens and evolving resistance patterns among pelvic inflammatory disease pathogens are reviewed. [Points & Pearls is a digest of Emergency Medicine Practice].