Subserosal pregnancy: Systematic review with proposal of new diagnostic criteria and ectopic pregnancy classification.

Ectopic pregnancy (EP) is a pregnancy where the growing blastocyst implants outside the endometrial cavity. EP account approximately for 0.5-1% of all pregnancies, and extrauterine implant is the leading cause of woman mortality in the first trimester of gestation. Non-tubal pregnancies (NTP) account for less than 5% of all EP. NTP are accompanied by a 7-8 times higher risk of maternal mortality when compared to tubal pregnancies, and their treatment might sometimes be very challenging. Subserosal pregnancy (SP) has been defined as rare variant of intramural pregnancy, where a portion of the gestational sac was surrounded only by the serosa of the uterus. Whereas the treatment of the ectopic pregnancies is crucial for patients' lives and for adequate fertility sparing and considering the need for surgical treatment in many cases, an early diagnosis is important; thus we believe it g might be useful to define some criteria to guide subserosal pregnancy identification, and to distinguish it from other types of non-tubal ectopic pregnancy. A systematic review on Pubmed, Scopus, Web of Science and Google Scholar was performed. Case reports, randomized controlled trials, prospective controlled studies, prospective cohort studies, retrospective studies, and case series were considered eligible. In all databases mentioned were considered manuscripts published from 1990 up to March 2023. Only four articles were eligible for inclusion in this review. All patients underwent to surgical management in laparoscopy. The main risk factors for this type of ectopic pregnancy were previous uterine surgery with opening of the endometrial cavity and assisted reproductive techniques procedures. Considering our results, we propose new classification and diagnostic criteria for subserosal pregnancy, to distinguish it from other types of non-tubal ectopic pregnancies with the aim to preserve fertility following the most correct management.

Management of early gestations with low beta-human chorionic gonadotropin conceived by assisted reproductive technologies: performance of M4 predictive model.

OBJECTIVES: To assess the safety and performance of the M4 model for classifying as high risk or low risk for ectopic pregnancy (EP) pregnancies conceived by assisted reproductive technologies (ART) that present with low beta-human chorionic gonadotropin (ß-hCG) concentration in early gestation. METHODS: This was a prospective cohort study of 243 pregnancies conceived by ART with low ß-hCG levels (5-50 IU/L) at 4 + 0 to 4 + 2 weeks' gestation. After subsequent ß-hCG testing at 48 h, pregnancies were classified according to the M4 model into the following categories: (i) high risk, probable EP/persistent pregnancy of unknown location (PPUL), when the risk for EP was ≥ 5%; (ii) low risk, probable intrauterine pregnancy (IUP), when the risk of EP was < 5% and the likelihood of IUP was greater than that of a failed pregnancy of unknown location (FPUL); and (iii) low risk, probable FPUL, when the risk of EP was < 5% and the likelihood of a FPUL was greater than that of an IUP. The predictive performance of the M4 model for EP and its ability to discriminate between high- and low-risk pregnancies was assessed using the final pregnancy outcome at 11 to 13 weeks of gestation as reference, which was classified as EP/PPUL, FPUL or IUP. RESULTS: The sensitivity and specificity of the M4 model in detecting a high-risk pregnancy (EP/PPUL) were 60.0% (95% CI, 43.6-74.4%) and 79.8% (95% CI, 73.8-84.7%), respectively. The area under the receiver-operating-characteristics curve of the M4 model for discriminating between high-risk and low-risk (FPUL/IUI) pregnancies was 0.72 (95% CI, 0.62-0.81). The model had a positive likelihood ratio of 2.97 (95% CI, 2.03-4.36) and a negative likelihood ratio of 0.50 (95% CI, 0.33-0.76). The kappa index was 0.30 (95% CI, 0.16-0.43), indicating a low degree of agreement between the model classification and the final diagnosis. No serious adverse events related directly to the application of the M4 model were observed, although 14 pregnancies classified ultimately as high risk had been categorized initially as low risk by the M4 model. Of these, seven resolved with expectant management, five with methotrexate (MTX) and two required laparoscopic surgery (one after failure of medical treatment with MTX and one after deviation from the follow-up protocol). There were no cases of EP/PPUL with additional complications or need for blood or other blood product transfusion. Of the 243 ART pregnancies with low ß-hCG concentration in early gestation, only 47 (19.3%) had an IUP, half (24/47) of which had an early miscarriage, resulting in only 9.5% (23/243) cases having an ongoing pregnancy. CONCLUSIONS: Application of the M4 model in pregnancies conceived by ART with low ß-hCG concentration in early gestation showed limited capacity in classifying them as being at low or high risk for EP, therefore, its use in pregnancies of this type is not recommended. No serious adverse events or complications related to the use of the model were observed. These pregnancies have a low probability of ending in an IUP as well as a high rate of early miscarriage. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Intrauterine ectopic pregnancy - ultrasound typing and treatment.

OBJECTIVES: To analyze the correlation between ultrasound typing and treatment modality of patients with an intrauterine ectopic pregnancy (cervical and cesarean scar). MATERIAL AND METHODS: We retrospectively enrolled 65 patients diagnosed with cesarean scar pregnancy (CSP) or cervical pregnancy (CP) between February 2014 and May 2018. The cases were divided into two types according to the ultrasound presentation with a gestational sac (GS, type I) or a heterogeneous mass (HM, type II). Type I was further divided into type Ia (< 8 weeks) and type Ib (≥ 8 weeks); type II was defined as type IIa (with poor or no vascularity) and type IIb (with rich vascularity). Three treatment methods were applied in each group. RESULTS: Of included cases, there were 53 CSP and 12 CP. There was no significant difference between Type I and Type II groups in any variable. The beta human chorionic gonadotropin (ß-hCG) level and gestational age of type IIb were significantly higher compared to type IIa (p < 0.05). There was a positive correlation between ultrasound categories and treatment methods (rs = 0.723, p = 0.000). Analysis of CSP cases of initial treatment failure indicated success rate of initial dilation and curettage (D&C) was dependent upon ultrasonic types, mean sac diameter, gestational age, hCG level, and number of cesarean sections. CONCLUSIONS: The features of ultrasound imaging might provide an additional reference for the selection of clinical treatment methods.

A novel method for typing of cesarean scar pregnancy based on size of cesarean scar diverticulum and its significance in clinical decision-making.

AIM: There is currently no universally accepted method for typing of cesarean scar pregnancy (CSP) to guide the choice of treatment approach. We introduce a new method for typing CSP and investigate its clinical significance. METHOD: Clinical data of 198 patients with CSP were collected and analyzed. The patients were divided into three types according to the size of their cesarean scar diverticula (CSD), measured by magnetic resonance imaging: type I (size of CSD ≤40 mm), type II (40 mm < size of CSD ≤70 mm) and type III (size of CSD >70 mm). RESULTS: With increase in the type level, the risk of adverse events increased significantly (χ2 = 36.345, P = 0.000). There was a significant difference in the choice of the treatment approaches in various types of the patients (χ2 = 27.106, P = 0.000). With increase in the type level, the invasiveness level of the treatment approach increased significantly (R = 0.405, P = 0.000). Further analysis found two other factors that influenced treatment choice. CONCLUSION: Our study, for the first time, demonstrates the value of size of CSD in typing of CSP and, thereby supplements the CSP typing system with a novel quantitative indicator. This typing method is of significance for evaluation of risk of CSP and guiding the choice of treatment approach. This typing method, combined with the two features of cesarean scar thickness and lesions protruding outside the uterine contour, will improve the risk assessment of CSP and the rationale of treatment plan formulation for this condition.

Clinical classification and treatment of cesarean scar pregnancy.

AIM: Embryo implantation in a cesarean scar resulting in a cesarean scar pregnancy (CSP) is a special form of ectopic pregnancy. The aim of this article is to present our clinical classification and therapeutic strategy for CSP and to assess the efficacy, safety, and social benefits. METHODS: We categorized CSP as either risky or stable. Risky CSP have a high risk of severe hemorrhage and should be treated immediately, while stable CSP patients have neither obvious vaginal bleeding nor significantly elevated serum ß-human chorionic gonadotrophin (ß-hCG). According to the thickness of the myometrial wall between the sac and the bladder and the location of the gestational sac, risky CSP were classified into three types and the thinner myometrial wall type (type I) was divided into three subtypes. Four treatment categories were applied to the corresponding types and subtypes of CSP. A total of 331 patients with CSP in our hospital were studied. The study group (n = 81) was treated based on our classification and optimized treatment system, while the control group (n = 250) underwent the conventional methods. We assessed the efficacy, safety, and social benefits of our classification and optimized treatment system. RESULTS: The values of intraoperative blood loss, operative time, hospital stay, and hospital cost in the study group were significantly lower than those in the control group (P < 0.05). Suction curettage was more frequently used in the study group (P < 0.005). CONCLUSION: Our clinical classification system and therapeutic strategy provide an effective and safe way to treat CSP patients resulting in reduced intraoperative bleeding, operative time, hospital days, and hospital cost.

Classification of pregnancies of unknown location according to four different hCG-based protocols.

STUDY QUESTION: How do four protocols based on serial human chorionic gonadotropin (hCG) measurements perform when classifying pregnancies of unknown location (PULs) as low or high risk of being an ectopic pregnancy (EP)? SUMMARY ANSWER: The use of cut-offs in hCG level changes published by NICE, and a logistic regression model, M4, correctly classify more PULs as high risk, compared with two other protocols. WHAT IS KNOWN ALREADY: A logistic regression model, M4, based on the mean of two consecutive hCG values and the hCG ratio (hCG 48 h/hCG 0 h) that classify PULs into low- and high-risk groups for triage purposes, identifies more EPs than a protocol using the cut-offs between a 13% decline and a 66% rise in hCG levels over 48 h. STUDY DESIGN, SIZE, DURATION: A retrospective comparative study of four different hCG-based protocols classifying PULs as low or high risk of being an EP was performed at a gynaecological emergency unit over 3 years. PARTICIPANTS/MATERIALS, SETTING, METHOD: We identified 915 women with a PUL. Initial transvaginal ultrasonography (TVS) findings categorised 187 of the PULs as probable intrauterine pregnancies (IUPs) and 16 as probable EPs. The rate of change in hCG levels over 48 h was calculated for each patient and subjected to three different hCG threshold intervals and a logistic regression model for outcome prediction. Each PUL was subsequently dichotomised to either low-risk (i.e. failed PUL/IUP) or high-risk (i.e. EP) classification, which allowed us to compare the diagnostic performance. In 'Protocol A', a PUL was classified as low risk if >13% hCG level decline or >66% hCG level rise was achieved; otherwise, the PUL was classified as high risk of being an EP. 'Protocol B' classified a PUL as low or high risk using cut-offs of 35-50% declining hCG levels and of 53% rising hCG levels. Similarly, 'Protocol C' used hCG level cut-offs published by NICE, 50% for declining hCG levels and 63% for rising hCG levels. Finally, if a logistic regression model 'Protocol M4' calculated a ≥5% risk of the PUL being an EP, it was classified as high risk, and otherwise the PUL was classified as low risk. When the time interval between two hCG measurements failed to meet an exact 48 h, extrapolation and interpolation of hCG values was made, using log linear transformation. MAIN RESULTS AND THE ROLE OF CHANCE: Protocols A, B, C and M4 classified 73, 66, 55 and 56% of PULs as low risk. The sensitivity for protocols A, B, C and M4 was 68% (95% confidence interval (CI) 61-75%), 81% (74-86%), 87% (82-92%) and 88% (83-93%), respectively. The specificity was 82% (80-85%), 77% (74-80%), 66% (62-69%) and 67% (63-70%) for protocols A, B, C and M4, respectively. All comparisons of sensitivity and specificity between the protocols were statistically significant except for protocol C versus protocol M4. In protocol C, 87% (66-97%) of misclassified EPs had rising hCG levels, compared with 19% (6-41%) for protocol M4 (P < 0.01). In a secondary analysis excluding probable IUPs and probable EPs, the results for 712 PULs were analysed. The sensitivity subsequently remained stable for all protocols. Protocol M4 reached a 78% (74-81%) specificity, which was significantly higher than 70% (66-74%) for protocol C (P = 0.01) and protocol M4 classified 63% of PULs as low risk compared with 58% for protocol C. LIMITATIONS, REASONS FOR CAUTION: The retrospective design of the study is a limitation. The results are derived from a population where laparoscopy played an important role in PUL management and diagnosis of EPs, although it did reflect real clinical practice. Although we tried to adhere to definitions of PUL and final outcomes as in previous studies and a recent consensus statement, potential differences in this regard must be acknowledged. Where the time interval between two serial hCG measurements deviated from 48 h we estimated 48 h hCG values. WIDER IMPLICATIONS OF THE FINDINGS: A logistic regression model, M4, classifies more PULs correctly as low risk in a selected PUL population without probable IUPs and EPs and identifies as many EPs, in comparison with the cut-offs available in the NICE guideline. This advantage for model M4 may result in a reduction of unnecessary follow-up visits, when fewer low-risk PULs are misclassified as high risk. These findings, however, ought to be clarified in a randomised controlled trial. STUDY FUNDING/COMPETING INTERESTS: The study was supported by LUA/ALF grant No. 70940. There are no competing interests.

Incorporating uterine artery embolization in the treatment of cesarean scar pregnancy following diagnostic ultrasonography.

OBJECTIVE: To evaluate combining uterine artery embolization (UAE) with other treatments for cesarean scar pregnancy (CSP). METHODS: A retrospective study included patients attending the First affiliated Hospital of Xi'an Jiaotong University, China, between March 1, 2009 and March 31, 2014, who were diagnosed with CSP. Patients were classified by ultrasonography as having endogenous CSP (CSP type I [CSP-I]) or exogenous CSP (CSP type II [CSP-II]). Patient outcomes were compared between patients who underwent treatment that included or excluded UAE. Patient records were reviewed and patients were interviewed by telephone to report on recovery following treatment. RESULTS: In total, 52 patients met the inclusion criteria. In patients with CSP-I, the blood loss, length of hospital stay, and time before restoration of normal ß human chorionic gonadotropin levels were significantly higher in patients who were treated with methotrexate combined with dilatation and curettage compared with those treated with UAE combined with dilatation and curettage (P<0.05). In patients with CSP-II, blood loss was lower in patients treated with UAE combined with excision compared with excision alone (P<0.001). CONCLUSION: Incorporating UAE in the treatment of CSP-I and CSP-II was safe; CSP should be properly classified to select the appropriate treatment.

Revisión del tratamiento del embarazo ectópico sobre cicatriz de cesárea previa. Una localización poco habitual / Review of the treatment of ectopic pregnancy in a previous cesarean section scar. A unusual location

La gestación implantada sobre cicatriz de cesárea previa es una forma poco habitual de embarazo ectópico, pero cuya incidencia ha aumentado en los últimos años en relación con las técnicas de reproducción asistida. Precisa de un diagnóstico temprano para poder minimizar las posibles complicaciones que pueden ocurrir (metrorragia, hemoperitoneo, rotura uterina,..). Disponemos de diferentes opciones diagnósticas y terapéuticas que revisaremos en este trabajo y que elegiremos en función de las características individuales de cada paciente (AU)

The pregnancy implanted on cesarean scar is a rare form of ectopic pregnancy, but whose incidence has increased in recent years in relation to assisted reproduction techniques. Accurate early diagnosis is needed in order to minimize the possible complications that can occur (metrorrhagia, hemoperitoneum, uterine rupture,..). We have different diagnostic and treatment options that will be reviewed in this paper and we will choose based on the individual characteristics of each patient (AU)

Diagnosis and management of intramural ectopic pregnancy.

Intramural pregnancy is a rare form of ectopic pregnancy, and little is known about its etiology, prevalence and natural history. There is no consensus regarding the ultrasound criteria necessary for the diagnosis of intramural pregnancy, and management strategies vary depending on the severity of clinical presentation, exact location of the pregnancy, viability and gestational age at diagnosis. We present four cases of intramural pregnancy diagnosed in a single institution that illustrate variability in their clinical presentation and difficulty in reaching the correct diagnosis. We also propose a set of ultrasound criteria to facilitate differential diagnosis between intramural and other types of uterine ectopic pregnancy.

Classification and management of cervical ectopic pregnancies: experience at a single institution.

OBJECTIVE: To classify cervical ectopic pregnancies including previous cesarean section scar pregnancies and to describe the management of cervical ectopic pregnancies. STUDY DESIGN: This was a retrospective analysis of all cervical ectopic pregnancies, including previous cesarean scar pregnancies, diagnosed at the Korea University Guro Hospital, Seoul, Korea, between January 1997 and October 2009 using transvaginal ultrasound. Clinical and demographic data were recorded in all cases. The pregnancies were categorized into three groups and subclassified into five types on the basis of transvaginal ultrasound and history of a previous cesarean delivery. The management of cervical pregnancies included medical treatment such as systemic methotrexate (single dose or multiple doses) or intraamniotic methotrexate and surgical treatment such as dilation and curettage (D&C), laparoscopic exploration and hysterectomy. RESULTS: Forty cervical ectopic pregnancies including previous cesarean section scar pregnancies were diagnosed. Cesarean section scar-related pregnancy (intramural type and nonintramural type) and cesarean section scar-unrelated pregnancy accounted for 10, 12 and 18 cases, respectively. D&C was performed in 21 patients and was successful in all cases except one. The success rate of medical treatment was 61.5% (8/13). Nine patients (22.5%) required a blood transfusion, and a total hysterectomy was performed in five patients (12.5%). CONCLUSION: Cervical ectopic pregnancies were classified, including previous cesarean scar pregnancies, into five types based on the findings of transvaginal ultrasound and history of a previous cesarean delivery.

An application of methods for the probabilistic three-class classification of pregnancies of unknown location.

OBJECTIVE: We developed and compared classifiers to predict the outcome of pregnancies of unknown location (PUL). This is a three-class problem, as the possible outcomes are failing PUL, intra-uterine pregnancy (IUP), or ectopic pregnancy (EP). We focused on probabilistic classification because of the importance of uncertainty information in medical decision making. METHODS AND MATERIALS: Nine methods were implemented, based on logistic regression (LR), multi-layer perceptrons, least squares support vector machines (LS-SVMs), and kernel logistic regression (KLR). The LR models involved manual checks for the necessity of input transformations or interaction effects. The classifiers were developed on the training set (n=508) and evaluated on the test set (n=348). We used two performance measures that only evaluate discriminatory potential, and two that investigate the exact probabilities and/or discriminatory potential. Classifier comparison was carried out using a ranking method. RESULTS: The classifier based on a combination of binary LR models using pairwise coupling (LR-PC) ranked first or second for each performance measure. LR-PC obtained test set areas under the receiver operating characteristic curve of 0.989, 0.988, and 0.924 for the prediction of failing PULs, IUPs, and EPs, respectively. Multi-class LR, multi-class KLR, and a combination of binary Bayesian LS-SVMs with radial basis function kernel were always ranked in the top five. Models with low emphasis on nonlinearity were ranked at the bottom. Importantly, LR-PC also performed better than previously developed classifiers based on multi-class LR. CONCLUSIONS: The prediction of PULs was good, most notably for failing PULs and IUPs. Logistic regression models performed remarkably well. Multi-class KLR also performed well, whilst nonlinearity was automatically incorporated and probabilistic outputs were directly given without Bayesian analysis or a combination of binary results. The selected inputs are reasonably objective and easy to obtain in clinical practice. Taken together, this study provided useful decision support tools for implementation in clinical practice.

Miscarriage and ectopic pregnancy 1: an overview.

This two-part unit explores miscarriage and ectopic pregnancy. This article, part 1, discusses definitions, classifications and signs and symptoms of both.

[Medical treatment of ectopic pregnancy and clinical score].

INTRODUCTION: Ectopic pregnancy is an important cause of morbidity and mortality worldwide. Furthermore, with earlier diagnosis, medical therapy with methotrexate can be offered and surgery avoided in some women, though the best regimen remains unclear. Although there have been advances in the management of ectopic pregnancy, there are still questions to be answered. OBJECTIVE: The use of clinical score was evaluated after the clinical treatment for selection of patients for medical treatment of ectopic pregnancy. METHOD: One hundred and twenty five patients were treated by methotrexate. The administration route was local, ultrasonographically controlled or intramuscular. The first dose of methotrexate was 50 mg and maximal total dosage was 200 mg. RESULTS: Methotrexate treatment of ectopic pregnancy was effective in 85% of cases. In the group of patients with clinical score under 10, the medical treatment was successful in 95% of cases. In the group of patients with clinical score over 14, the medical outcome was successful in 33% of cases. The administration route did not influence the treatment outcome. CONCLUSION: Methotrexate treatment of ectopic pregnancy is a very effective manner of treatment. Clinical (numeric) score is very useful for selection of patients with ectopic pregnancy and may have prognostic value for medical treatment outcome.

Bilateral ectopic pregnancy.

Bilateral simultaneous ectopic pregnancy is a very rare clinical condition. Two different subsets of patients can be distinguished: women presenting with the disease as a result of spontaneous conception and those with the condition after undergoing assisted reproduction procedures. This article reviews and analyzes 42 cases of bilateral ectopic pregnancies reported in the last 10 years, proposes a new classification of the disease, and presents some data that should be useful for the clinician who confronts this difficult entity.

Semantics and pitfalls in the diagnosis of cornual/interstitial pregnancy.

OBJECTIVE(S): To clarify the respective definitions of cornual and interstitial pregnancy and to explore the difficulties in diagnosing these entities, particularly in the context of Müllerian fusion defects. DESIGN: Case study. SETTING: Community and tertiary-care hospitals. PATIENT(S): Female with recurrent pregnancy loss initially diagnosed with an interstitial pregnancy but subsequently found to have a cornual pregnancy in a bicornuate/septate uterus. INTERVENTION(S): Imaging with two-dimensional and three-dimensional ultrasound, hysterosalpingogram, serial beta-hCG measurement, administration of methotrexate and misoprostol, and aspiration and curettage. MAIN OUTCOME MEASURE(S): Measurement of beta-hCG levels and pathologic evaluation of aspiration and curettage material. RESULT(S): Correct diagnosis and eventual termination of cornual pregnancy and identification of a uterine anomaly were achieved. The process led to the development of an enhanced understanding of diagnostic modalities and their limitations with regard to the entities under discussion. CONCLUSION(S): Accurate diagnosis of an interstitial pregnancy requires that those reading and reporting ultrasounds use consistent, precise nomenclature. Clinicians must remain cognizant of the limitations of ultrasound in distinguishing cornual (intrauterine) from interstitial (ectopic) pregnancies and the influence of uterine anomalies on this distinction.

Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy.

OBJECTIVES: Pelvic ultrasound performed by emergency physicians can identify a definite diagnosis in the majority of symptomatic first-trimester pregnant patients on the initial emergency department (ED) visit. However, a significant minority of such patients are diagnosed as having an indeterminate pregnancy state requiring further testing and consultation. The authors investigated the final outcome of patients with an initial indeterminate ED first-trimester pelvic ultrasound examination in the setting of an interdepartmental protocol to rule out ectopic pregnancy. METHODS: This was an observational prospective cohort study performed at a regional, urban ED with more than 100,000 patient visits over a 13-month period. Pelvic ultrasound for first-trimester patients was prospectively performed by emergency physicians with gynecologic consultation for lack of intrauterine pregnancy (IUP) ultrasound findings. IUP was defined as a fundal gestational sac with either a yolk sac or a fetal pole. Pelvic ultrasounds were classified into diagnostic categories including definite IUP, embryonic demise, molar pregnancy, definite ectopic pregnancy, and indeterminate. For all patients with indeterminate pelvic ultrasound findings, final diagnostic categories and patient outcome were established by the use of patient records, obstetric ultrasound reports, laboratory studies, operative reports, and pathology reports. All patients with ectopic pregnancy were followed for mode of treatment. Descriptive statistics were calculated. RESULTS: A total of 1,490 ED first-trimester pelvic ultrasound examinations were performed over 13 months establishing the following diagnostic rates for initial ED visit: IUP 1,037 (70%), demise 127 (8%), definite ectopic pregnancy 24 (2%), molar pregnancy 2 ( < 1%), and indeterminate 300 (20%). The 300 indeterminate patients were classified using the above protocol into the following final diagnostic categories: embryonic demise 158 (53%), IUP 88 (29%), ectopic pregnancy 44 (15%), and unknown outcome 10 (3%). Indeterminate patients with ectopic pregnancy were treated with methotrexate in 25 of 44 cases (57%) and surgically in 16 of 44 cases (36%); there were no laparotomies. In contrast, ectopic pregnancy patients diagnosed on initial ED visit were treated surgically in 20 of 24 cases (83%), including four laparotomies. CONCLUSIONS: The outcome of symptomatic first-trimester patients with indeterminate ED pelvic ultrasounds is poor, with significantly high rates of embryonic demise and ectopic pregnancy. However, those indeterminate patients with the eventual diagnosis of ectopic pregnancy have a higher rate of medical methotrexate treatment and a reduced rate of invasive surgical treatment compared with ectopic pregnancy patients diagnosed at initial ED visit.

Gestación ectópica sobre cicatriz de cesárea anterior: caso clínico y revisión de la literatura / Ectopic pregnancy in a cesarean section scar: case report and review of the literature

La gestación sobre la cicatriz de una cesárea anterior es la forma más rara de embarazo ectópico que puede acarrear graves complicaciones, como la rotura uterina o hemorragias graves, y requiere la realización de histerectomía. Sin embargo, con ecografía transvaginal es posible su diagnóstico precoz y la aplicación de tratamiento conservador. Se han descrito varias modalidades terapéuticas, y se ha señalado la inexistencia de una que sea idónea para todos los casos. Presentamos un caso de gestación ectópica sobre la cicatriz de una cesárea anterior diagnosticada mediante ultrasonografía en la sexta semana de amenorrea. Se realizó tratamiento conservador con éxito mediante la administración combinada de metotrexato sistémico e intrasacular, negativizándose los valores de gonadotropinas en la sexta semana. Las diferentes opciones terapéuticas, sus ventajas e inconvenientes, se discuten en el texto (AU)

Acute and chronic presentation of ectopic pregnancy may be two clinical entities.

OBJECTIVE: The diagnosis of ectopic pregnancy (EP) is often confirmed at presentation (acute), but often requires serial beta-hCG levels to confirm the diagnosis (chronic). The purpose of this study is to analyze whether these clinical presentations represent a spectrum of disease. DESIGN: The retrospective cohort study of 452 patients diagnosed with EP at the University of Pennsylvania in the years 1990-1999. SETTING: University of Pennsylvania, Philadelphia, Pennsylvania. PATIENT(S): Four hundred fifty-two patients diagnosed with EP. Patients diagnosed with EP were divided into two groups according to the time of diagnosis. MAIN OUTCOME MEASURE(S): A total of 37 parameters were examined including historic and demographic factors, findings at presentation, and treatment and outcome variables. RESULT(S): The two groups were similar in terms of historic EP risk factors. Multivariable analysis demonstrates that women with a chronic presentation were less likely to have received fertility medications (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.06-0.84), less likely to present with pain (OR 0.29; 95% CI 0.12-0.71), have a lower beta-hCG level at presentation (9,849 mIU/mL +/- 16,726 vs. 1,787 mIU/mL +/- 4,717), lower chance of rupture (OR 0.19; 95% CI 0.05-0.73), and less frequently have blood type 0. CONCLUSION(S): Women diagnosed with ectopic pregnancy can be categorized into two groups, those with an acute presentation and those with a chronic presentation. Differences in risk factors, presentation, and outcome may reflect differences in trophoblast viability or invasive potential.