ABSTRACT
In this chapter an overview is given of the best available evidence on the conservative treatment for tubal ectopic pregnancy, i.e., expectant management and medical treatment with systemic methotrexate. From the two randomized controlled trials on expectant management, no conclusions can be drawn yet. It may be that women with low serum hCG levels need not be treated at all, but more research needs to be done in this subgroup of women to reach firm conclusions. Systemic methotrexate in a fixed multiple-dose i/m regimen can be recommended for hemodynamically stable women with an unruptured tubal ectopic pregnancy and no signs of active bleeding presenting with serum hCG concentrations<3,000 IU/l. In women with serum hCG concentrations<1,500 IU/l, a single-dose methotrexate regimen can be considered.
Subject(s)
Abortifacient Agents, Nonsteroidal/administration & dosage , Chorionic Gonadotropin/blood , Infertility, Female/therapy , Methotrexate/administration & dosage , Pregnancy, Tubal/therapy , Abortifacient Agents, Nonsteroidal/adverse effects , Female , Humans , Infertility, Female/psychology , Laparoscopy/adverse effects , Laparoscopy/methods , Laparoscopy/psychology , Methotrexate/adverse effects , Pregnancy , Pregnancy, Tubal/blood , Pregnancy, Tubal/psychology , Randomized Controlled Trials as Topic , Ultrasonography, PrenatalABSTRACT
OBJECTIVE: To compare single dose systemic methotrexate (50 mg/m2) with laparoscopic surgery for the treatment of unruptured tubal pregnancy. DESIGN: An open, pragmatic, prospective randomised trial. SETTING: Departments of obstetrics and gynaecology at three hospitals in Auckland, New Zealand. PARTICIPANTS: Clinically stable women with an unruptured tubal pregnancy diagnosed by transvaginal ultrasound and quantitative serum beta-hCG measurement. Inclusion criteria included a serum beta-hCG concentration < 5,000 IU/L, and a tubal pregnancy of < 3.5 cm diameter. MAIN OUTCOME MEASURES: Treatment success, physical and psychological functioning, side effects, and subsequent ipsilateral tubal patency. RESULTS: Two hundred and eighteen women with ectopic pregnancies were seen at the three hospitals. 79 women (36% eligibility rate) were eligible for trial entry and 62 women (78% recruitment rate) were recruited. Twenty-six of the 28 women (93%) randomised to laparoscopic surgery required no further treatment, compared with 22 of the 34 women (65%) randomised to methotrexate (95% CI of difference in success rate 10 - 47%; P < 0.01). Two women (7%) in the laparoscopic surgery group had persistent trophoblast. Nine women (26%) in the methotrexate group required more than one dose of methotrexate and five women (15%) underwent laparoscopy during follow up. In the laparoscopy group three women (11%) had negative laparoscopies and two women (7%) had were found to have a ruptured fallopian tube at the time of surgery. Women treated with methotrexate had significantly better objective physical functioning scores but there were no differences in any other psychological outcomes. Women treated with methotrexate experienced greater and more prolonged vaginal bleeding. The likelihood of methotrexate treatment failure was greater at higher serum beta-hCG concentrations. Ipsilateral tubal patency rates were similar in each group. CONCLUSION: This trial shows that in the treatment of tubal pregnancy single dose systemic methotrexate is a less effective treatment than laparoscopic salpingotomy. It is well tolerated, but should only be offered as an alternative to surgery to women who have mild symptoms and present at low serum beta-hCG concentrations. In our population this likely to be no more than a quarter of women presenting with a tubal pregnancy.
Subject(s)
Abortifacient Agents, Nonsteroidal/administration & dosage , Laparoscopy/methods , Methotrexate/administration & dosage , Pregnancy, Tubal/drug therapy , Pregnancy, Tubal/surgery , Abortifacient Agents, Nonsteroidal/adverse effects , Adult , Anxiety/etiology , Chorionic Gonadotropin/blood , Depression/etiology , Female , Health Status , Humans , Hysterosalpingography/methods , Laparoscopy/adverse effects , Laparoscopy/psychology , Methotrexate/adverse effects , Pregnancy , Pregnancy, Tubal/psychology , Prospective Studies , Surveys and Questionnaires , Treatment OutcomeABSTRACT
We report on a 29-year old patient, who was treated as an inpatient in 95 different hospitals (altogether 173 times) within 7 years. The gynaecologist can suspect Münchausen's syndrome, if the following aspects are recorded: dramatic clinical admissions patterns, (frequently out of the normal consultation time); a history of several operations and many short stays in different hospitals. Special care in diagnostics should be taken to avoid further unnecessary surgical interventions.
Subject(s)
Munchausen Syndrome/psychology , Pregnancy, Tubal/psychology , Adult , Diagnosis, Differential , Female , Humans , Munchausen Syndrome/diagnosis , Munchausen Syndrome/surgery , Patient Care Team , Postoperative Complications/diagnosis , Postoperative Complications/psychology , Pregnancy , Pregnancy, Tubal/diagnosis , Pregnancy, Tubal/surgeryABSTRACT
Our primitive brain has the capacity to recall visual, auditory, olfactory, tactual, and postural memories. Consciously we all set limitations on our abilities to recall. The technique described here suggests that all of us can recall meaningful sensory experiences with the help of multiple subconscious reviews of an event. We are aware of moods unconsciously and can assign colors to these moods. The unconscious mind can localize the true site of pain even when the patient is consciously sure the pain is localized elsewhere. The methods of exploration are described, and possible values of the methods are pointed out.