Plasma metabolomics for diagnostic biomarkers on ectopic pregnancy.

Metabolomics is a relatively novel omics tool to provide potential biomarkers for early diagnosis of the diseases and to insight the pathophysiology not having discussed ever before. In the present study, an ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS) was employed to the plasma samples of Group T1: Patients with ectopic pregnancy diagnosed using ultrasound, and followed-up with beta-hCG level (n = 40), Group T2: Patients with ectopic pregnancy diagnosed using ultrasound, underwent surgical treatment and confirmed using histopathology (n = 40), Group P: Healthy pregnant women (n = 40) in the first prenatal visit of pregnancy, Group C: Healthy volunteers (n = 40) scheduling a routine gynecological examination. Metabolite extraction was performed using 3 kDa pores - Amicon® Ultra 0.5 mL Centrifugal Filters. A gradient elution program (mobile phase composition was water and acetonitrile consisting of 0.1% formic acid) was applied using a C18 column (Agilent Zorbax 1.8 µM, 100 x 2.1 mm). Total analysis time was 25 min when the flow rate was 0.2 mL/min. The raw data was processed through XCMS - R program language edition where the optimum parameters detected using Isotopologue Parameter Optimization (IPO). The potential metabolites were identified using MetaboAnalyst 5.0 and finally 27 metabolites were evaluated to be proposed as potential biomarkers to be used for the diagnosis of ectopic pregnancy.

Evaluation of Clinical Efficacy of Contrast-Enhanced Ultrasound in the Diagnosis of Ectopic Tubal Pregnancy.

Objective: To explore whether contrast-enhanced ultrasound (CEUS) can improve tubal ectopic pregnancy detection rate, tubal dilation, tubal hematoma, and gestational sac. Methods: This retrospective study included 34 patients with suspected ectopic pregnancy who underwent contrast-enhanced ultrasound at Dongzhimen Hospital of Beijing University of Chinese Medicine between March 2021 and September 2016. Of these, 27 patients were confirmed to have tubal pregnancy by laparoscopic surgery and histopathology. Four ultrasound physicians (2 experts and 2 non-experts) conducted a retrospective analysis of conventional color Doppler ultrasound and the combination of conventional color Doppler ultrasound with contrast-enhanced ultrasound (color Doppler ultrasound + CEUS). They analyzed the differences in confidence levels and reproducibility in identifying tubal dilation, tubal hematoma, and gestational sac implantation sites. Additionally, the characteristic features of ectopic pregnancy on contrast-enhanced ultrasound were summarized, including gestational sac morphology, triple ring sign, enhancement patterns (branching or punctate), tubal dilation (with or without hematoma), contrast enhancement of tubal walls, and presence of free fluid. Results: In the expert group, the correct identification rate of the gestational sac implantation site on ultrasound images increased from 13/34 (38.2%) with conventional color Doppler ultrasound to 20/34 (58.8%) with color Doppler ultrasound + CEUS, the differences were statistically significant (38.2% vs. 58.8%, P = .039). The correct identification rate of tubal dilation increased from 6/34 (17.7%) to 25/34 (73.5%) (P = .001), and the correct identification rate of tubal hematoma increased from 3/34 (8.8%) to 17/34 (50.0%) with color Doppler ultrasound + CEUS (P < .001). In the non-expert group, the correct identification rate of the gestational sac implantation site increased from 8/24 (23.5%) with conventional ultrasound to 19/34 (55.9%) with ultrasound + CEUS (P = .003). The correct identification rate of tubal dilation increased from 6/34 (17.7%) to 23/34 (67.7%) (P < .001), and the correct identification rate of tubal hematoma increased from 3/34 (8.82%) to 12/34 (35.3%) with color Doppler ultrasound + CEUS (P = .012). Conclusion: The analysis of contrast-enhanced ultrasound images provides characteristic features and diagnostic points for tubal ectopic pregnancy, including gestational sac, thick ring sign, tubal dilation, and tubal dilation with hematoma. This approach improves the accuracy of partial pregnancy of unknown location (PUL) diagnosis and reduces the technical dependence on ultrasound personnel.

The feasibility of introducing early pregnancy assessment unit in Nigerian hospitals: A pilot study from a private hospital in Enugu, Southeast Nigeria.

Background: Early pregnancy assessment unit (EPAU) is a dedicated unit that provides specialist care such as definitive ultrasonographic and biochemical assessment to women who have or have had vaginal bleeding or pain before 16 weeks of pregnancy. Such patients usually have a positive pregnancy test with a scan showing pregnancy of an unknown location, previous ectopic pregnancy, recurrent miscarriages, or previous molar pregnancy. Such a holistic and prompt approach leads to better outcome in the management of women with early pregnancy and other complications. Aim: This study aimed to describe the diagnosis and outcome of early pregnancy pain and bleeding, managed by rapid ultrasonographic and biochemical assessments by a dedicated gynecological team in a private hospital to determine the feasibility of establishing early pregnancy assessment units (EPAUs) in Nigeria. Materials and Methods: This is a cross-sectional study of eligible cases of early pregnancy bleeding and pain in a private gynecological hospital in Enugu, Nigeria. Results: During the 9-year study period, 160 women with early pregnancy pain or bleeding were analyzed. The mean age of the participants was 32.3 ± 7.2 years, and they were mostly multipara (68.7%) and Christians and of the Igbo tribe (91.3%). The final diagnosis after clinical and radiological evaluations showed that the majority had miscarriages (82.5%), while 17.5% had ectopic gestations. All the participants had their definitive diagnosis and treatment within 24 hours of presentation. There was no recorded case of maternal death. Conclusion: EPAUs are feasible in a Nigerian setting provided that trained, dedicated staff and equipment are provided.

Scar Tissue after a Cesarean Section-The Management of Different Complications in Pregnant Women.

The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium.

Impact of hysterosalpingography after operative treatment for ectopic pregnancy in Taiwan: A 16-year Nationwide Population-Based Analysis.

By retrieving records from Taiwan's National Health Insurance (NHI) system's database, the current study aimed to investigate the impacts of hysterosalpingography (HSG) to patients after ectopic pregnancy (EP) operations in Taiwan.In this retrospective cohort study, insurance claims data from 1997 to 2013, derived from a cohort of 1 million people randomly sampled to represent all NHI beneficiaries, were analyzed. Patients after ectopic pregnancy (EP) operations were identified via the inclusion of the corresponding NHI procedure codes. We further divided the patients into 2 groups by whether received subsequent HSG, EP-HSG, and EP-no-HSG. Patients with history of previous pregnancies (PP) and subsequent HSG were grouped as PP-HSG. We sought to evaluate the following pregnancies (FP) rate, interval to FP in EP-HSG compared with that in EP-no-HSG, and PP-HSG.EP-HSG had significantly higher FP rate odds ratio than EP-no-HSG (OR, 1.64; 95% CI, 1.24-2.16, P < .001). EP-HSG had lower FP rate odds ratio than that in PP-HSG, but no significant difference (33.1% vs 34.6%, P  =  .654). The INTERVAL(HSG-FP) in EP-HSG was no significantly different from that in PP-HSG (843.34 ±â€Š82 days vs 644.72 ±â€Š24.30 days, P  =  .077). There was significant positive correlation between FP after EP and number of HSG (r  =  0.070, P < .001). There were significant negative correlation between FP and EP age (r  =  -0.270, P < .001), FP and INTERVAL(EP-HSG) (r  =  -0.212, P  =  .001). The multivariate analysis showed that INTERVAL(EP-HSG) less than 1 year is the predictor factor of INTERVAL(EP-FP) (hazard ratio: 1.422; 95% CI: 1.130-1.788; P = .003). It was evident that the longer the INTERVAL(EP-HSG), the lower the FP rate odds ratio; and the older the EP age, the lower the FP rate odds ratio. (OR, 95% CI; >1 year: 0.59, 0.41-0.86; >2 year: 0.42, 0.32-0.55; >25 years old: 0.47, 0.38-0.57; >30 years old: 0.29, 0.24-0.35; >35 years old: 0.12, 0.08-0.18, all P < .001).Receiving HSG after EP, short INTERVAL(EP-HSG), EP age less than 30 years old, had significant positive impacts on the FP. We encourage shortening the INTERVAL(EP-HSG), and the counseling of women on the most appropriate way to conceive thereafter.

Management of Cesarean Deliveries and Cesarean Scars With Osteopathic Manipulative Treatment: A Brief Report.

Cesarean scars pose a unique set of risks for women who have had previous cesarean deliveries. Between 1996 and 2007, the rate of trial of labor after previous cesarean delivery increased, along with reported rates of uterine rupture and other complications. Consequently, trial of labor after previous cesarean delivery and resultant vaginal birth after cesarean delivery have decreased and cesarean delivery has increased. With nearly one-third of women having cesarean delivery, the rate of rare complications such as cesarean scar ectopic pregnancy has also increased. An integration of osteopathic manipulative treatment techniques into the management of cesarean deliveries and cesarean scars has yet to be defined. The author presents 4 cases of cesarean delivery in which osteopathic manipulative treatment was integrated with successful outcomes.

[Update on Current Care Guidelines: Ectopic pregnancy]. / Ektooppinen (kohdunulkoinen) raskaus.

Ectopic pregnancy should be suspected it a woman of fertile age has lower abdominal pain and irregular vaginal bleeding. Symptoms range from almost none to shock. The diagnosis is based on a quantitative serum pregnancy test (hCG) and transvaginal ultrasound. An acute situation requires emergency surgery, whereas patients with mild symptoms should be treated policlinically by follow-up or a single intramuscular dose (1 mg/kg) of methotrexate. No folic acid supplementation is needed. In later pregnancies their location should be verified by transvaginal ultrasound done by the seventh gestational week at the latest.

Ectopic pregnancy rate and treatment utilization in a large managed care organization.

OBJECTIVE: To estimate the ectopic pregnancy rate at Kaiser Permanente, Northern California, during 1997-2000. METHODS: Computerized data systems covering inpatient, outpatient, and pharmacy records were reviewed for evidence of ectopic pregnancies during the study period. Denominator data were calculated from computerized utilization and membership data for the same period. RESULTS: We identified 2,617 ectopic pregnancies that occurred between 1997 and 2000 among 126,451 reported pregnancies for an annual rate of 20.70 per 1,000 reported pregnancies and 1.03 per 1,000 women 15-44 years old. There was no evidence of a trend over time in these data. The rate increased with increasing age. Approximately 35% of these women were medically treated, and we observed an increase over time in the proportion of women who were medically treated. CONCLUSION: Using computerized data systems in a large integrated health delivery system, we found that the rate of ectopic pregnancy in 1997-2000 was similar to the national rate in 1990-1992, when national data were last available. These data suggest that the ectopic pregnancy rate is not increasing, although differences in the study populations need to be kept in mind. Medical treatment seems to be increasing over time.

Electrodessication of a cervical heterotopic pregnancy.

A cervical heterotopic assisted reproductive technology (ART) pregnancy was diagnosed sonographically. The cervical pregnancy was electrodesiccated with a Kleppinger device. The intrauterine pregnancy was carried to term.

Complete abortion of a nonviable cervical pregnancy following methotrexate treatment.

Cervical pregnancy is an uncommon ectopic pregnancy that accounts for approximately <1% of extrauterine gestations. This condition is associated with an extremely high risk of massive hemorrhage and previously often required hysterectomy. Current early ultrasonographic diagnosis and medical management in conjunction with other conservative measures, which include uterine artery embolization and intracervical balloon tamponade, have enabled conservation of the uterus. A young nulliparous patient ultrasonographically diagnosed with a cervical pregnancy and early fetal demise at 11 and 4/7 weeks gestation was managed with high-dose methotrexate and folinic acid rescue treatment. On the second day after treatment was initiated she spontaneously passed an intact gestational sac accompanied by minimal hemorrhage. Treatment was continued, with decreasing serum beta subunit of human chorionic gonadotropin levels and subsiding hemorrhage. Subsequent surgical measures were not required. This case suggests that complete abortion of a cervical pregnancy not necessitating surgical measures can occur.

Cervical pregnancy treated with a single intravenous administration of methotrexate plus oral folinic acid.

Cervical pregnancy is a rare form of ectopic pregnancy and at present there is no consensus as to the most appropriate treatment. A patient with a 6-week cervical pregnancy was successfully treated with a single intravenous administration of methotrexate and oral folinic acid without any adjuvant therapy Her recovery was uncomplicated. She subsequently conceived and was delivered by Caesarean section of a live healthy male baby. The efficacy of the described regimen in the management of a cervical pregnancy requires further assessment. This modality of treatment does not appear to adversely affect fertility and future pregnancies.

Conservative treatment using a methotrexate-lipiodol emulsion containing non-ionic contrast medium for a cervical ectopic pregnancy.

We present a case in which a viable cervical pregnancy was successfully treated with preservation of the uterus. A 26 year old female presented with a 6 week cervical pregnancy with acute moderate bleeding. On the day of admission the patient underwent embolization of the descending uterine artery to decrease the bleeding. The following day, 4 mEq potassium chloride and methotrexate (MTX)(1 mg/kg) dissolved in saline was injected into the amniotic cavity using transvaginal sonographic guidance. The fetal heart beat ceased; however, the urinary beta-human chorionic gonadotrophin (HCG) concentration increased and the gestational sac size also increased. After a second injection of an emulsion of MTX (1 mg/kg) dissolved in a non-ionic contrast medium, iopamidol and lipiodol, the betaHCG concentration in the urine began to decrease. After a third injection with the same emulsion, the cervical mass became necrotic. The betaHCG concentrations in the urine and serum were undetectable and the external cervix returned to normal 44 days after admission. No vaginal bleeding or significant side effects of MTX were observed throughout the treatment. An in-vitro dissolution test revealed that the dissolution rate of MTX was slower from MTX-lipiodol-iopamidol with sonication than without sonication. The present study indicates that use of an MTX emulsion enables slow release of MTX and may be applicable for conservative treatment of ectopic pregnancies, including cervical pregnancy.

High dose methotrexate infusion with leucovorin rescue for treatment of ectopic pregnancy.

The purpose of this article is to evaluate the effectiveness, side effects, and complications of high dose methotrexate infusion with leucovorin rescue in select patients with ectopic pregnancy. Between January 1991 and November 1994, 28 patients with ectopic pregnancies were prospectively treated with methotrexate (100 mg/m2 intravenous bolus followed by a 200 mg/m2 infusion over six hours) with leucovorin rescue. Twenty-seven of 28 patients (96%) were successfully treated. Only one patient (4%) required a second course of methotrexate to reach a normal hCG titer. One patient failed methotrexate infusion 45 days after treatment at a hCG titer of 12 mIU/mL. No Gynecologic Oncology Group grade 3 or 4 clinical, biochemical or hematologic toxicities occurred. Uterine bleeding and abdominal pain, not requiring transfusion or hospitalization, occurred in 71% and 56% of patients. The authors conclude that high dose methotrexate infusion with leucovorin rescue is a highly effective, well tolerated, nonsurgical treatment for select patients with ectopic pregnancy.