Interstitial pregnancy management and subsequent pregnancy outcome.

We report on management and subsequent fertility outcome of interstitial pregnancy in a retrospective cohort study (Canadian Task Force classification II-3) at a university affiliated teaching hospital. Of 706 women with extrauterine pregnancy, 14 consecutive women with interstitial pregnancy were treated by methotrexate, laparotomy or laparoscopy between 1997 and 2007. The first four women, with significant hemoperitoneum, were treated by laparotomy. Of the next 10 women, four were selected for medical treatment with methotrexate. Only one case was treated successfully. The other six women had laparoscopic treatment. Of nine laparoscopies, one was converted to laparotomy due to excessive blood loss during the procedure. Of nine women desiring a child, three were infertile, whereas six conceived with an intrauterine pregnancy. A change from diagnosis later in pregnancy and laparotomy to more conservative treatment, mainly by laparoscopy, suggests a possibly better subsequent pregnancy rate.

The optimal cutoff serum level of human chorionic gonadotropin for efficacy of methotrexate treatment in women with extrauterine pregnancy.

OBJECTIVE: To evaluate the efficacy of methotrexate treatment for extrauterine pregnancy and define criteria for prediction of success. METHODS: Of 829 patients with an ectopic pregnancy admitted to E. Wolfson Medical Center, Holon, Israel, from January 1997 through December 2009, 238 had asymptomatic tubal pregnancies and increasing serum ß-human chorionic gonadotropin (ßhCG) levels. These patients were treated with a single intramuscular injection of 50mg of methotrexate (MTX) per square meter of body surface. Success was defined as undetectable ßhCG levels without the need for a surgical intervention. RESULTS: The groups of patients successfully treated (n=167 [70%]) and unsuccessfully treated (n=71 [30%]) were compared. They were similar regarding age and gravidity. The initial serum ßhCG level was significantly higher in the latter group than in the former (3798 mIU/mL vs. 1601 mIU/mL, P<0.01). The success rate was 88% when initial ßhCG levels were less than 1000 mIU/mL, 71% when they were between 1000 and 2000 mIU/mL, and only 59% when they were between 2000 and 3000 mIU/mL. CONCLUSION: Methotrexate treatment is a safe and effective alternative to surgery. However, patients with initial ßhCG levels higher than 2000 mIU/mL should only be offered the surgical approach.

Clinical utility of esophagogastroduodenoscopy in the management of recurrent and intractable vomiting in pregnancy.

OBJECTIVE: To determine the impact of esophagogastroduodenoscopy (EGD) on the clinical management of pregnancy women with recurrent vomiting and their pregnancy outcome. STUDY DESIGN: Retrospective evaluation of 60 pregnant women who underwent diagnostic EGD in the first trimester of pregnancy. RESULTS: Pregnant women were divided into 2 groups according to the indications for EGD: group 1, intractable vomiting with or without epigastric pain (n = 49) and group 2, vomiting and gastrointestinal bleeding (n = 11). The endoscopic findings found in both groups were esophagitis (43%), gastritis (17%), diaphragmatic hernia (17%) and normal EGD (28%). The diagnostic yield for EGD was 69% for group 1 and 82% for group 2. EGD was helpful for clinical management when performed for suspected gastrointestinal bleeding rather than for other indications. Mean gestational age at delivery, fetal weight and mean Apgar score did not differ by groups. No fetal malformations were observed. CONCLUSION: Recurrent intractable vomiting in pregnancy may be accompanied by esophagitis or peptic disease in a significant proportion of patients. Based on the significant pathologies amenable to medical therapy, a therapeutic trial with a proton pump inhibitor during hyperemesis gravidarum seems warranted. EGD can be safely performed in pregnancy with no maternal or fetal complications.

Role of sonography in the diagnosis of retained products of conception.

OBJECTIVE: To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings. METHODS: This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty-one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor. RESULTS: Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false-positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false-positive rates were 28.9% and 51.5%, respectively. CONCLUSIONS: Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false-positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Midtrimester abortion in patients with a previous uterine scar.

OBJECTIVE: To investigate whether extraamniotic prostaglandin E2 (PGE2) for midtrimester pregnancy interruption in women with a scarred uterus has any adverse effects compared to those without an uterine scar. STUDY DESIGN: Two hundred and sixty-two women who underwent second trimester (16-27 gestational weeks) termination of pregnancy were enrolled in this study. Thirty-one women with a uterine scar were compared with 231 patients without a scarred uterus. Extraamniotic PGE2 was applied in serial doses of 200 mcg every 2 h up to 20 doses. Intravenous infusion of oxytocin was added in cases when the fetus was not expelled. Curettage was performed in the majority of the patients. RESULTS: The two groups were similar for indications for pregnancy termination, maternal age and gestational age. Gravidity and parity were significantly higher in the group with an uterine scar. The mean induction to abortion time and the complication rate were similar in both groups. No uterine rupture was observed. CONCLUSION: Extraamniotic PGE2 for midtrimester termination of pregnancy is a safe procedure with a low complication rate, even in patients with an uterine scar.

Clinical significance of the floating fetal head in nulliparous women in labor.

OBJECTIVE: To examine the course of labor in nulliparous women in active labor with a floating fetal head. STUDY DESIGN: A prospective, cohort study of nulliparous women presenting in active labor at term with a floating fetal head (station > or = -3, n = 108) or engaged fetal head (n = 241). All patients were examined by a senior physician. Assignment to the study or control group was noted in the investigator's records. However, management of labor was at the discretion of the labor ward team on duty. RESULTS: Cesarean section rates for failure to progress were significantly higher in the study group (17.1% versus 4.2%, P < .0001), and the second stage of labor was prolonged (65.3 +/- 27.1 versus 54.9 +/- 30.2 minutes, P < .03). None of the women who had a persistently floating fetal head at 7 cm of cervical dilation delivered vaginally. Birth weights were larger (P < .03) and Apgar scores lower (P < .0001) in the study group. The lengths of the active phase and instrumental delivery rates were similar in the two groups. CONCLUSION: Nulliparous women presenting in active labor at term with a floating head are at substantially increased risk of cesarean section for abnormal progress of labor. However, the majority of patients will still deliver vaginally. A persistently floating head with advanced cervical dilation (7 cm) should prompt consideration of cesarean section since little is to be gained by waiting.