Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis.

INTRODUCTION: Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS: We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER: PROSPERO: CRD42021214093. RESULTS: 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS: Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

OBJECTIVE: To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION: All patients of reproductive age. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

[Management and pregnancy outcomes of heterotopic pregnancy].

Objective: To investigate the clinical features, diagnosis and treatments of heterotopic pregnancy (HP) and demonstrate the outcomes of HP after the surgical treatment of ectopic pregnancies. Methods: A retrospective analysis was performed on 144 cases of HP in Women's Hospital, School of Medicine, Zhejiang University from January 2003 to December 2016. Results: (1) Clinical features of HP:the average age of patients was (30.8±3.8) years old, body mass index (BMI) was (21.9±2.9) kg/m(2), and was diagnosed at (6.5±1.3) weeks gestational age. Four patients (2.8%) were naturally pregnant, 10 patients (6.9%) received ovulation induction, and 130 patients (90.3%) had received infertility treatments. Fifty-one patients (35.4%) had no clinical symptoms, and 93 patients (64.6%) had clinical symptoms included vaginal hemorrhage,abdominal pain and hemorrhagic shock caused by intraperitoneal hemorrhage. The location of ectopic pregnancy was most common in the fallopian tubes (59.0%, 85/144) and the interstitial part (33.3%,48/144) . (2) Ectopic pregnancy treatment of HP:thirteen patients underwent expectation treatment, and the remaining 131 cases underwent surgical treatment, including laparoscopy (n=56) , laprotomy (n=52) , and fetal reduction (n=23) . Among the 131 patients underwent surgery, intrauterine pregnancy were found inevitable abortion in 6 cases preoperatively. The total early abortion rate after surgery was 14.4% (18/125) ; the second operation rate was 3.1% (4/131) . (3) Intrauterine pregnancy outcome of HP: 120 intrauterine fetal were survival, the total live birth rate was 83.3% (120/144) .One hundred and seven intrauterine fetal were survival after operation and the live birth rate after operation was 85.6% (107/125) . Twenty-nine cases were premature delivery and the premature delivery rate was 24.2% (29/120) . There was no significant differences between tubal HP and interstitial HP group in the preterm birth rate [25.8% (16/62) vs 26.3% (10/38) ; χ(2)=0.003, P>0.05]. Cesarean section rate of delivery in interstitial HP group was significantly higher than that in tubal HP group [97.4% (37/38) vs 59.7% (37/62) ], and the difference was statistically significant (χ(2)=17.400, P<0.05) . Conclusions: The clinical manifestations of HP are diversified, combining of high risk factors, clinical symptoms and ultrasonography could improve the accuracy of diagnosis. Different method has been used to treat HP, such as laparoscopic or laparotomy and fetal reduction, and there are varying degrees of failure rate and postoperative abortion rate. We should consider carefully to adopt expectant management. Through individualized treatment, most HP could get good perinatal outcomes.

Adaptation of a Brazilian university hospital to clinical treatment of ectopic pregnancy: Lessons learned over 17 years.

OBJECTIVE: To describe and compare the annual success rates of medical treatment in the analyzed period and to evaluate the associated factors. METHODS: Retrospective study with 158 women with tubal pregnancy followed up over 17 years. Statistical analysis was performed using the Cochran-Armitage test, the χ2 test, Mann-Whitney test, and multiple logistic regression. RESULTS: The success rate was 47.4%. There was a trend of significant change in the success rate of clinical treatment over time (Z = 2.01, P = 0.044); it was associated to undergoing treatment between 2012 and 2017 (P = 0.028), the absence of abdominal pain (P = 0.020), receiving a higher dose of methotrexate (P < 0.001), and less time hospitalized (P < 0.001). In the final statistical model, we observed that receiving a higher dose of methotrexate (P = 0.025, odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.06), having a low serum ß-HCG concentration before treatment (P = 0.003, OR 0.87, 95% CI 0.79-0.95), and not having abdominal pain (P = 0.004, OR 4.26, 95% CI 1.61-11.28) were factors associated with a higher chance of successful clinical treatment for tubal pregnancy. CONCLUSION: A greater chance of success was observed among women undergoing clinical treatment from 2012 onwards, who used higher doses of methotrexate, were asymptomatic at admission, and had low concentrations of ß-hCG.

Spontaneous ectopic pregnancy occurring in the remnant tube after ipsilateral salpingectomy: a report of 2 cases.

Ectopic pregnancy occurring in the remnant tube after ipsilateral salpingectomy is assumed to be rare. We report 2 cases of spontaneous ectopic pregnancy occurring in the remnant tube that were treated surgically. Even in spontaneous pregnancy, attention should be paid to the remnant tube so as not to miss an ectopic pregnancy after previous salpingectomy.

Spontaneous Unilateral Tubal Twin Ectopic Pregnancy.

Background: Unilateral tubal twin pregnancies occur in approximately 1 of every 125,000 spontaneous pregnancies. Because of the paucity of data, little guidance for the appropriate management of a twin tubal ectopic pregnancy is available. Case Report: A 40-year-old female presented to the emergency department (ED) with a 2-day history of vaginal bleeding associated with lower abdominal pain. The patient was hemodynamically stable with signs of an acute abdomen. Pelvic examination elicited clinical findings consistent with potential ectopic pregnancy. Urine pregnancy test in the ED was positive. Serum beta-human chorionic gonadotropin was 23,359 mIU/mL, and transvaginal ultrasound showed findings concerning for a twin ectopic pregnancy. Diagnostic laparoscopy with right salpingostomy was successful, and the patient had an uncomplicated postoperative course. Conclusion: Healthcare providers should have a high index of clinical suspicion for ectopic pregnancies. Unilateral tubal twin ectopic pregnancies, while rare, can be adequately diagnosed with transvaginal ultrasound. Laparoscopic salpingostomy provides conservative and successful treatment of unilateral tubal twin gestation with short recovery time. Medical treatment with methotrexate has not been adequately studied in this clinical scenario, but further exploration of this management modality should be considered.

Pretreatment serum human chorionic gonadotropin cutoff value for medical treatment success with single-dose and multi-dose regimen of methotrexate in tubal ectopic pregnancy.

OBJECTIVE: To investigate individual pretreatment serum human chorionic gonadotropin (hCG) cutoff value for medical treatment success with single-dose and multi-dose regimen of methotrexate in tubal ectopic pregnancy. METHODS: Eighty-five women who received methotrexate for the treatment of tubal ectopic pregnancy during 2003 to 2015 were selected. Fifty-three women received a single-dose regimen and 32 women received a multi-dose regimen. Medical treatment failure was defined as necessity of surgical treatment. The medical treatment success rate was estimated in both regimens and the pretreatment serum hCG titer to predict the success was assessed by receiver operating characteristics curve analysis. RESULTS: Pretreatment clinical and laboratory parameters were similar between group of single-dose regimen and multi-dose regimen. Treatment success rate was 64.2% in the single-dose regimen group and 71.9% in the multi-dose regimen group (P>0.05). Pretreatment serum hCG titer was an independent prognostic factor for treatment success in each regimen. Serum hCG cutoff value to predict the treatment success was 3,026 IU/L in single-dose regimen group and 3,711 IU/L in multi-dose regimen group. CONCLUSION: We recommend use of single-dose regimen when pretreatment serum hCG <3,026 IU/L but multi-dose regimen may be favored when initial serum hCG level between 3,026 and 3,711 IU/L.

Intrauterine device use and risk of tubal pregnancy: an Indonesian case-control study.

BACKGROUND: We assessed the risk of tubal pregnancy among women who (1) were currently using an intrauterine device (IUD) and (2) had discontinued IUD use while still sexually active and at risk of pregnancy using data from a multicentre case-control study of married women conducted in Indonesia. METHODS: Cases were 560 women diagnosed with histologically confirmed ectopic pregnancy from April 1989 to August 1990 at any one of 11 participating hospitals. Controls were 1120 non-pregnant women similar in age and place of residence to the cases. In-person interviews were conducted to collect information regarding current and past contraceptive use as well as other demographic and personal characteristics. RESULTS: Women currently using an IUD were considerably less likely than women not currently using contraception, but more likely than users of hormonal or surgical means of contraception, to develop a tubal pregnancy. Women who had discontinued using an IUD had a 70% subsequent increase in risk of tubal pregnancy (adjusted RR = 1.7, 95% Cl: 1.1-2.5) relative to women who had never used an IUD. This increase in risk was most pronounced in women who reported multiple episodes of IUD use and, to a lesser extent, in women with a long (> 3 year) duration of IUD use. CONCLUSIONS: The associations we observed are similar to those previously reported in studies conducted in developed countries. The results are of particular interest because this study was conducted in a location in which the Dalkon Shield IUD was never available, and among a population of married, gravid women for whom IUD use is generally considered most appropriate.

Repeat ectopic pregnancy: a 16-year clinical survey.

This study includes 347 cases of ectopic pregnancy. A comparison was made between patients having one ectopic pregnancy, those having a repeat ectopic pregnancy, and those whose first pregnancy was an ectopic one. Emphasis was placed on obstetric history and the reproductive future of these patients. Obstetric performance was poor for all groups of patients studied. In the patient whose first pregnancy was ectopic, total reproductive performance was complicated by an increased risk of a repeat ectopic pregnancy. The incidence of repeat ectopic pregnancy was 11.2%. The average interval between ectopic pregnancies was 2.83 years; 80% of the repeat pregnancies occurred within 4 years of the first ectopic episode. Obstetric outcome was likely to be poor after the second ectopic pregnancy.

PIP: A study was conducted to assess the possible obstetric future for patients with at least 1 incidence of ectopic pregnancy. The study involved 347 cases of ectopic pregnancy. Comparison was made among patients who had 1 such pregnancy, patients whose 1st pregnancy was extrauterine, and patients with repeat ectopic pregnancies. The most common site of ectopic pregnancy was the uterine tube. The left tube was more often affected in patients with a single ectopic pregnancy; the right tube more often in repeat cases. Most patients were in their 30s when the ectopic pregnancy occurred. There was a higher incidence of repeat ectopic pregnancies among low parity women. For repeat patients, all had experienced rupture the 1st time. Treatment was most often either salpingectomy or salpingectomy with cornual resection. There were no characteristic differences between women with 1 and women who experienced repeat ectopic pregnancies. The obstetrics outlook, performance, and prospects for a viable infant were poor for patients with an experienced ectopic pregnancy.

A collaborative study of the progesterone intrauterine device (Progestasert). The World Health Organization Task Force on Methods for the Regulation of Implantation.

A randomised double blind study of a plain T-shaped IUD and an active T-shaped IUD releasing 65 micrograms/day of progesterone, has been completed in four centres. A study of 1320 progesterone-releasing IUD's in parous women for 9660 women months of use significant to 18 months, gave a pregnancy rate of 1.0 +/- 0.4, expulsion of 4.7 +/- 0.6 and removals for pain and bleeding of 6.0 +/- 0.7. A detailed analysis of the menstrual bleeding patterns in these patients gave details of the number and length of bleeding and spotting episodes, count of bleeding days, and count of spotting episodes and days for four one-hundred-day reference periods. While the plain IUD contributed a significant number of intermenstrual spotting and bleeding days, the progesterone-releasing IUD contributed more spotting days.

PIP: Two IUD studies were conducted at 4 centers in England, Hungary, Denmark, and Switzerland. The first one was a double blind study in which 317 plain T devices and 359 T devices releasing 65 ug/day were inserted in 676 women and followed up for 12 months. In the second study medicated T devices were inserted in 1302 parous women and followed up for 12 months after which new medicated devices were inserted in the remaining 715 patients and followed up for an additional 6 months. In the 1st study, the accidental pregnancy rate was much higher for the plain devices than for the active devices; the respective rates were 9.4 and 0.9. The continuation rates were 74.4 for the active devices and 65.8 for the plain IUDs. Expulsion and medical removals were similar for both types of devices. In the second study, after the 1st year of use, the expulsion and medical removal rates decreased and the continuation rate increased. The expulsion rate for 12 months of use was 4.7 and for 18 months of use it was 2.5. The medical removal rate for 12 months 6.0 and for 18 months the rate was 2.7. The continuation rate at 12 months was 80.2 and increased to 89.7 for 18 months of use. The patients in both studies were asked to keep daily records of any bleeding during the study period. Analysis of these records indicated that during the initial 100 days of use, the progesterone IUDs were associated with a higher incidence of spotting than the plain devices; however, after 100 days of use, the differences were reduced and eventually disappeared. No ectopic pregnancies occurred among the progesterone IUD users but a tubal pregnancy was recorded for a patient using the plain device. No perforations were reported. Tables included: 1) age and parity by type of device; 2) pregnancy, expulsion, removal, and continuation rates by type of device for the double blind study and for the second study at 12 months and at 18 months; and 3) frequency and length of bleeding and spotting episodes for each consecutive 100 days of use of plain and active devices.

The contraceptive efficacy of 10mg or 25mg of norethindrone given orally on day 15-22 of the human menstrual cycle.

PIP: 25 mg or 10 mg norethindrone (NET) were administered on Day 15-22 of the menstrual cycle. 71 women participated during 319 cycles in the 25 mg group and 59 participated during 381 cycles in the 10 mg group. About 75% of the women had been pregnant before. Before each cycle treatment, plasma progesterone (P) and estradiol (E) were determined. 5 ng/ml or more of 5 NG/ML OR MORE OF P was regarded as postovulatory. 1.2-4.9 ng/ml P with a concommittant E level of 100 pg/ml were regarded as periovulatory. In the 25 mg group, of 87 blood samples from Day 15, 10.3% had postovulatory P levels, while 23% had periovulatory levels of P and E. Corresponding frequencies for 81 samples in the 10 mg group were 11.1% and 18.5% respectively. 17 pregnancies occurred (Pearls index of 29), 7 in the 25 mg group and 10 in the 10 mg group. 2 of the 10 in the mg group were tubal pregnancies. The early development of the remaining 15 pregnancies was normal, as judged by the absence of vaginal bleeding, normal P levels and normal histology of the fetal tissue after curettage. The NET contraceptive efficacy of this dose schedule is too low to merit clinical use.^ieng

Tubal conservation with ectopic gestations. A reappraisal.

Ectopic pregnancies have shown an increasing trend during the past decade. Factors that appear to be responsible are the intrauterine device (IUD), fallopian tube surgery (ligation reversals, reconstructive tuboplasty), and more effective antibiotics against pelvic inflammatory disease (precluding radical pelvic surgery). Our ability to diagnose an ectopic pregnancy at an earlier gestation (prior to rupture) through the use of highly sensitive pregnancy tests (Beta-HCG), ultrasonography, and diagnostic laparoscopy, has significantly altered our approach in treatment. Because these ectopic gestations are seen in a younger population, older nulliparous patients, and patients who desire future fertility, earlier diagnosis precludes an emergency approach to a now-elective procedure. In this paper, we will explore the pros and cons of conservative management for ectopic pregnancies, emphasizing present day evaluation and microsurgical approaches for repair.

PIP: This article examines causal factors of ectopic pregnancy, discusses management with emphasis on tubal conservation, and updates information on diagnosis, fertility maximization, and minimization of risks of recurrent ectopic gestations. The common factor in ectopic gestations appears to be a delay in the transport of the fertilized ovum to the uterus, allowing the embryo to develop invasive trophoblast. Factors that appear to have increased the incidence of ectopic pregnancy over the past include increased sexual exposure, more effective theraphy for pelvic inflammatory disease, IUDs, tubal surgery, and surgical sterilization reversals. 77% of extrauterine gestations occur in the middle and distal thirds of the fallopian tube, with clinical manifestations largely determined by the site of implantation. Abdominal pain, amenorrhea/vaginal bleeding, and a pelvic mass are the classic signs of an ectopic pregnancy. Newer diagnostic procedures including serum human chorionic gonadotropin-beta subunit assay pregnancy testing supported by ultrasonography and laparoscopy have allowed the vast majority of tubal pregnancies to be diagnoses before rupture, permitting surgery to be undertaken more for the purpose of preserving fertility than for saving the mother's life. Factors in selecting candidates for conservative surgery include medical stability of the patient, parity, desire for future pregnancy, age under 35, mid or distal tubal gestation, prior ectopic gestation or tubal surgery. Considerations influencing the surgical approach for appropriate candidates include location of the pregnancy, condition of the involved and contralateral tube and ovary, pelvic anomalies, previous surgery, and need for ancillary procedures. If the ectopic gestation is located in the mid to distal segment of the fallopian tube, a segmental resection or salpingostomy using microsurgery should give a good anatomic and functional result. A review of the literature indicates that, contrary to prevailing opinion, recurrent etopic gestations are not more common in patients undergoing tubal conservation than in those undergoing more radical procedures. Recent data have shown term pregnancy rates of 40-55% and recurrent ectopic pregnancy rates of 5% in patients with conservative procedures, the improved rate being attributed to availability of microsurgical techniques, finer suture and minimal surgical trauma, which lead to less adhesions and scarring. tudies have indicated that use of Dextran minimizes pelvic adhesion formation, decreasing anatomic distortion leading to subsquent infertility or ectopic pregnancy.

Function and malfunction of the Fallopian tubes in relation to gametes, embryos and hormones.

PIP: After a brief historical review of studies on the Fallopian tubes, their functional anatomy is considered with regard to cilia; secretory cells, the mucosa, musculature, innervation, and vasculature. Muscula activity is treated in relation to the transport of gametes and embryos, and secretory activity in relation to the maturation of gametes and development of embryos. The isthmus may function critically in regulating sperm numbers available for fertilization while simultaneously acting as a temporary sperm reservoir, and entry of eggs into the ampulla may stimulate release and capacitation of spermatozoa from the lower regions of the tube. Because of the rapidity of egg transport to the ampullary-isthmic junction, the latter is the site of fertilization in most mammals though apparently this is untrue in women. Subsequent passage of the embryo along the isthmus is under the influence of gonadal steroids, and appears to be regulated locally by an interplay of alpha- and beta-adrenergic receptor activity in the myosalpinx and by tissue prostaglandins, as well as by the extent of edema in the mucosa. The possibility that embryonic secretion of hormones contributes to this control should be recognized as should the role of steroid-induced anomalies of egg transport in the etiology of tubal pregnancies. Tubal fluid is no ed to be composed of serum transudate and specific secretion containing some unique protein(s), and is regulated by the prevailing balance of ovarian hormones, but a trophic influence of the embryo is again considered. Finally, reference is made to clinical problems in the light of evidence obtained from experimental animals, and it is reasoned that attempts to regulate human fertility by modified tubal function could prove to be unsatisfactory.^ieng

Sexually transmitted diseases and the risk of tubal pregnancy.

Women who were hospitalized for tubal pregnancy in five hospitals in King County, Washington, between 1975 and 1979 were interviewed regarding a prior history of gonorrhea, genital herpes, genital warts and trichomoniasis. Their responses were compared to those of women who delivered a live-born child during the same period. Multiple logistic regression was used to control for the effects of race, gravidity, smoking, Dalkon Shield use, douching, number of sexual partners and history of additional sexually transmitted diseases. The risk of tubal pregnancy in women who reported a history of gonorrhea, relative to that in other women, was 5.1. As compared to controls, women with tubal pregnancy more often reported a history of genital herpes and a history of trichomoniasis.

[A case of tubal pregnancy caused by an intrauterine contraceptive device]. / Un caso di gravidanza tubarica da contraccettivo intrauterino.

PIP: A young patient, a wearer of a copper IUD for about 18 months, was hospitalized for bleeding and severe pain. Several tests were performed and a diagnosis of tubal pregnancy made. The patient underwent surgery for rupture of the left oviduct. Presence of corpus luteum was found in the right ovary. It is possible that the presence of the copper IUD helped in the formation of substances similar to prostaglandins, which caused peristaltic contractions in the left oviduct.^ieng

[2 clinical cases of tubal pregnancy after incorrect use of the combined pill]. / Su due casi clinici di gravidanza tubarica dopo assunzione scorretta di pillola combinata.

PIP: 2 cases of tubal pregnancy in patients on combined oral contraceptives are examined. Both patients had not only failed to take the pill correctly, but had stopped taking it in midcycle. This led to nidation of the fertilized ovun in the left tube, with consequent rupture of the same. Implantation in the tube may be due to slower physiological recovery of tubal motility, as opposed to that of the ovulatory and cervical mechanisms. The article also contains a discussion of the contraceptive mechanism of combined pills.^ieng

A 6 year review of ectopic pregnancy.

PIP: During the period 1972-77, there were 106 cases of ectopic pregnancy, confirmed by laparotomy, at Kandang Kerbau Hospital, Singapore. This makes an incidence rate of 1/340 deliveries. This rate is actually much lower than the actuality because many other cases were admitted to other surgical units and not recognized. This rate is an increase over an earlier rate at the same hospital. Since only 3 of the women in this series had a history of pregnancy termination, the increase cannot be attributed to liberalization of legal abortion since 1972. The majority of these cases occurred among women over 30. 16 of the cases had a history of infertility, corresponding to the general knowledge that the ectopic pregnancy rate among those who attend infertility clinics is 7 times higher than normal. Management of the cases is discussed. Salpingectomy was performed in almost 3/4 of the cases and salpingo-oopherectomy in 18.8%. The conception rate after ectopic pregnancy was approximately 50%; after a salpingectomy, the conception was 74%. Therefore, salpingectomy is the recommended management for such cases. In this series under study, there was an 8.5% repeat ectopic pregnancy rate. There was no mortality and morbidity was minimal. Early diagnosis and treatment with conservative management is recommended.^ieng

Ruptured tubal pregnancy following tubal sterilization.

PIP: Prior tubal sterilization should be regarded as a possible etiologic factor in the pathogenesis of ectopic pregnancy. The authors present the case of a 32-year-old woman, para 4, who presented to Kenyatta National Hospital in October 1985 with complaints of lower abdominal pain and vomiting. She had undergone tubal ligation in February 1985. Examination revealed a ruptured ectopic pregnancy in the lateral part of the left tube. There was active bleeding from the rupture. The right distal stump was intact, and the right proximal stump had no obvious defect. There was a corpus luteum in the left ovary. Ectopic gestation after tubal sterilization apparently occurs when there is recanalization and formation of a proximal tuboperitoneal fistula, allowing sperm passage and fertilization of the ovum in the peritoneal cavity, on the ovarian surface or within the ductal tubal lumen. Although the technical details of this patient's sterilization were not available, laparotomy indicated that a modified Pomeroy procedure using absorbable sutures had been performed. The failure rate for the Pomeroy procedure is estimated at 0.25-2%. Since the incidence of ectopic pregnancy following tubal sterilization is about 1 in 13 in some parts of the world, potential sterilization acceptors should be counseled about this complication and a diagnosis of ectopic gestation should be considered whenever a patient with a previous history of tubal ligation presents with signs or symptoms of pregnancy.^ieng

[Extrauterine pregnancy after sterilization via a laparoscope]. / Ekstrauterin graviditet efter sterilisation gennem laparoskop.

Information was collected from the Danish National Patient Register and the Danish Board of Health about the frequency of rupture of extrauterine pregnancies among a normal population and among women who had previously been sterilized via a laparoscope. Significantly fewer extrauterine pregnancies were observed among the group of women who had undergone sterilization. Ruptured tubal pregnancies were significantly more frequent among women who had previously been sterilized as compared with the remainder of the fertile female population. It is therefore important that women who have previously undergone laparoscopic sterilization should contact their general practitioner if the slightest suspicion of pregnancy arises.

PIP: Information was collected from the Danish national patient registry and the Danish Ministry of Health on the frequency of rupture of extrauterine pregnancies among a normal population and among women who had previously been sterilized via laparoscopy. Significantly fewer extrauterine pregnancies were observed among the women who had undergone sterilization. Ruptured tubal pregnancies were significantly more frequent among women who had previously been sterilized, compared with the remainder of the fertile female population. It is important that women who have previously undergone laparoscopic sterilization should contact their physician if the slightest suspicion of pregnancy arises.

[Some causes of ectopic pregnancy in the aspect of clinical and anatomo-pathological studies]. / Niektóre przyczyny ciazy pozamacicznej na podstawie badan klinicznych i anatomopatologicznych

PIP: 9.98% of all gynecological surgical interventions made at the Clinic in Zabrez from 1965 to 1971 were for ectopic pregnancy. 157 cases of ectopic pregnancy were chosen at random for clinical analysis. Microscopic examinations of the excised oviduct were made in order to establish the cause of tubular implantation. The cause was determined in 45.6% of all the cases. Causal factors were chronic salpingitis (33%), endometriosis (11.4%), and tuberculosis (1.2%). In the formation of acute salpingitis (54.4% of these cases) a major incidence of passed spontaneous and artificial abortion was revealed. It is felt that postoperative examination of material should cover not only the presence of the fetal ovum but also the microscopic appearance of the oviducts' walls. In this manner it is thought that the cause may become more evident, making prophylaxis of ectopic pregnancy more possible.^ieng