Undiagnosed ectopic pregnancy: a retrospective analysis of 31 'missed' ectopic pregnancies at a teaching hospital.

The management of 255 surgically proven cases of ectopic pregnancy, treated at a teaching hospital over a 5-year period, was retrospectively reviewed to determine the proportion of cases where the diagnosis was 'missed' at initial presentation. Thirty-one patients (12%) had presented and been discharged with an incorrect diagnosis, then subsequently readmitted for definite treatment of a tubal ectopic pregnancy. In this group, the mean time from initial presentation to definitive surgery was 8 days. Ten of the 31 women with 'missed' ectopic pregnancies (32%) underwent salpingectomy, whereas the rate of salpingectomy in those women whose ectopic pregnancy was correctly diagnosed at first presentation was 19.5% (44 of 224). We conclude that delays in the diagnosis of ectopic pregnancy may be associated with an increased rate of salpingectomy, which may in turn reduce prospects for future fertility, a finding not previously canvassed in the literature. The factors contributing to misdiagnosis of ectopic pregnancy are discussed and compared with those reported in other studies.

Intra-amniotic methotrexate versus CO2 laser laparoscopic salpingotomy in the management of tubal ectopic pregnancy--a prospective randomized trial.

Tubal pregnancy can be safely and effectively managed by MTX or CO2 laparoscopic salpingotomy techniques. Methotrexate may be superior because of its simplicity, requiring only basic laparoscopic skills, whereas laparoscopic salpingotomy necessitates operative laparoscopic input.

Beta HCG levels after conservative treatment of ectopic pregnancy: is a plateau normal?

In 32 women with unruptured tubal ectopic pregnancies we undertook conservative laparoscopic treatment [local injection of 20 mg methotrexate (n = 18), laser salpingotomy (n = 14)]. The results of serial quantitative beta HCG measurement were followed until either a negative level was reached or until rising levels necessitated alternative/additional therapy. Plateaued values of beta HCG were observed in both the successful (n = 16) and the unsuccessful cases (n = 5). To test the hypothesis that daily variation in the assay could account for some or all of the observed plateaued results in successful cases, the sera were retested serially on the same 'run'. In only one case did laboratory variation account for the observed plateau. The clinical implications of the findings are discussed. We conclude that serially monitored beta HCG results after conservative treatment of ectopic pregnancy may show plateaued values without indicating failure of treatment.

Methotrexate injection of tubal ectopic pregnancy. A logical evolution?

OBJECTIVE: To test the efficacy and possible side effects of a single 20 mg dose of methotrexate injected at the time of laparoscopy, in the treatment of tubal ectopic pregnancy. DESIGN: The study was a non-randomised non-blinded prospective clinical trial. SETTING: The study was carried out at two tertiary referral hospitals. PATIENTS: Eighteen patients with unruptured tubal ectopic pregnancies and in a stable haemodynamic condition were offered entry into the study and all of these agreed. INTERVENTIONS: At diagnostic laparoscopy, 20 mg of methotrexate in 0.8 mL was injected by fine needle in or around the ectopic gestation. MAIN OUTCOME: Patients were followed up as outpatients by serial blood tests until resolution of the ectopic pregnancy was demonstrated by a return of the level of beta-human chorionic gonadotrophin to the normal range. RESULTS: There was one failure of treatment. The ectopic pregnancy resolved in the remaining 17 patients. There were no side effects attributable to methotrexate and tubal patency was demonstrated in the eight patients tested by hysterosalpingography.

The effect of unilateral versus bilateral tubal cannulation and the number of oocytes transferred on the outcome of gamete intrafallopian transfer.

A comparison of results of GIFT procedures using unilateral and bilateral tubal cannulation was made. There was no difference in outcome between these two methods, with the unilateral approach having some advantages over the bilateral procedure. Pregnancy rates decreased as the number of oocytes transferred was reduced.

CO2 laser laparoscopic salpingotomy for treatment of tubal ectopic pregnancies: potential limitations.

Linear salpingotomy was performed on 16 patients using the CO2 laser laparoscopically directed. Median operating time was 60 minutes (range 40-100) and all patients were discharged on the first postoperative day. There were 4 patients in whom persistence of trophoblast activity was detected, 2 of whom were treated surgically and 2 by oral methotrexate therapy.

CO2 laser laparoscopic salpingotomy for treatment of tubal ectopic pregnancies: potential limitations.

Linear salpingotomy was performed on 16 patients using the CO2 laser laparoscopically directed. Median operating time was 60 minutes (range 40-100) and all patients were discharged on the first postoperative day. There were 4 patients in whom persistence of trophoblast activity was detected, 2 of whom were treated surgically and 2 by oral methotrexate therapy. Conservative techniques for the treatment of ectopic pregnancy have proliferated since 1953 being made possible because of the early presentation of patients and the more sensitive methods of intrauterine pregnancy detection. In the past decade laser technology has been added to the armamentarium of infertility surgeons and there have been 2 reports of its successful use in cases of ectopic pregnancy. The present study aimed to examine the application of this technique in our patient population and to investigate any associated problems.

Unilateral gamete intrafallopian transfer: the preferred method?

Pregnancy occurred in 8 of 14 patients with the unilateral transfer of three or four oocytes at GIFT procedures. These results suggest that unilateral GIFT may be at least as successful as the bilateral approach. It would appear that unilateral GIFT rather than in vitro fertilization should be used for patients with one normal fallopian tube, and if the pregnancy rates with unilateral GIFT are substantiated, then this would be preferable to the bilateral approach, as operating time is shorter and there is less risk of trauma to the fallopian tubes at the time of gamete transfer.

Comparison of transabdominal and transvaginal pelvic ultrasonography for ovarian follicle assessment in in vitro fertilisation.

The emergence of transvaginal ultrasound-guided oocyte retrieval provided an opportunity to review and improve the traditional transabdominal ultrasonic approach for follicular tracking in in vitro fertilisation (IVF). This technique requires a full bladder, which may cause extreme discomfort. Hence, to provide both effective and comfortable monitoring, we instituted a study comparing transabdominal and transvaginal ultrasonography, with regard to patient preference and follicular number, size and dominance, in patients undergoing IVF and gamete intrafallopian transfer (GIFT). Commencing usually on day 9 of the treatment cycle, 45 patients were scanned on 55 occasions, initially abdominally (with a full bladder) and subsequently vaginally, using a transvaginal 7.5 MHz sector transducer. Follicular number was identical in 78% of cases, with the majority of the remaining patients showing an extra follicle on vaginal assessment. There were no significant differences in overall or dominant follicular diameters with either technique. Overall, 85% unashamedly preferred the vaginal approach. We believe that tracking follicular development in IVF treatment cycles is efficient and popular using the vaginal sector transducer and accordingly have ceased all assessments using the abdominal probe. Subsequently, 450 follicle scans have been performed with virtually the unanimous approval of our patients.

Twin pregnancy: prematurity and perinatal mortality.

An 8-year (1976-1984) retrospective analysis was undertaken of the management and outcome of 245 twin pregnancies delivered at Flinders Medical Centre, Adelaide. The incidence of twin delivery was 1 in 69 with a perinatal mortality of 85.7 per 1,000 total births. Amongst 42 perinatal deaths, 28 were associated with preterm labour at or before 28 weeks' gestation. If bed rest in hospital is to be implemented as a possible means of improving perinatal outcome in twin pregnancy it needs to be effected between 21 and 28 weeks' gestation; there is no rational theoretical basis for hospitalization beyond this time.

Danazol: objective assessment in the treatment of endometriosis.

The objective assessment of Danocrine (Danazol, Winthrop) in the treatment of endometriosis was hampered in the 1970s by the absence of a universally accepted classification. The American Fertility Society (AFS) classification, proposed in 1979, has now become widely accepted. However, there is a lack of recorded objective data utilizing the AFS score before and after Danazol therapy. In a series of 51 patients with endometriosis, who underwent laparoscopy, then received Danazol, 800 mg daily for 6 months, and had a repeat laparoscopy, there was a statistically significant improvement in the AFS score in Stage I and II disease.

Pregnancy-specific beta 1-glycoprotein as a screening test for at-risk pregnancies.

A serum assay was performed on 605 women for pregnancy-specific beta 1-glycoprotein (SP-1) between 31 and 34 weeks' gestation. SP-1 was also estimated for 255 of these women between 15 and 20 weeks' gestation, coincidental with maternal serum alpha-fetoprotein (AFP) screening. A clinical classification of pregnancy outcome was constructed for ech group. SP-1 values at 31 to 34 weeks' gestation in pregnancies that resulted in the birth of a small-for-dates (SFD) infant were statistically different from those in normal pregnancies (p less than 0.001). A value of 100 mg per liter was chosen as a suitable discriminatory level at 31 to 34 weeks, below which SP-1 had a sensitivity of 64%, a predictive value of 24%, and defined a relative risk of 5.3 for SFD infants. These parameters compare favorably with published data on the use of human placental lactogen as a screening test. No statistical relationship was found between SP-1 values at 31 to 34 weeks and birth weight, placental weight, parity, or other abnormal pregnancy outcomes. SP-1 screening at 15 to 20 weeks' gestation showed no correlation with serum AFP or with other parameters studied.