Early prediction of methotrexate treatment outcome in tubal ectopic pregnancy based on days 0 and 4 human chorionic gonadotropin levels.

AIM: Methotrexate (MTX) is an efficient treatment for ectopic pregnancy, used according to 'single-dose' protocol. Treatment success is evaluated on days 4 and 7 after dose administration, and defined as a decline of ≥15% in beta-human chorionic gonadotropin (ß-hCG) levels, with a positive predictive value of 93%. A decrease on day 4 ß-hCG levels was determined to be a good predictor for treatment success. We retrospectively examined changes in ß-hCG levels between days 0 and 4 after MTX treatment as an early predictor for treatment outcome. METHODS: The 'success group' consisted of patients with resolved ectopic pregnancy after a single MTX dose and 'failure group' included patients who required additional MTX doses or underwent surgery after the first dose. For each group, demographic and pregnancy data were analyzed as well as initial (admission day), days 0, 4 and 7 ß-hCG levels. RESULTS: Of 159 women included in the study, MTX treatment was successful in 117 patients (73.6%) while 42 patients (26.4%) were defined as treatment failure. In the success group, most patients (58.9%) demonstrated a decrease in ß-hCG values between days 0 and 4 as opposed to the failure group in which an increase in ß-hCG values was observed (76.2%). Decrease of >18% in ß-hCG levels was predictive of treatment success (positive predictive value 92%). Increase in ß-hCG values is less predictive of treatment failure with positive predictive value of 54%. CONCLUSION: Differences in ß-hCG levels between days 0 and 4 may serve as an early predictor for treatment outcome.

Pregnancy of unknown location: the value of frozen section analysis and its relation to Beta-hCG levels and endometrial thickness

Abstract Objective Frozen section examination is a rapid method for identifying products of conception in endometrial curetting, yet its accuracy is inconclusive. The purposes of this study is to determine the accuracy of frozen section analysis of endometrial curetting in pregnancies of unknown location, and to verify the relation of β-human chorionic gonadotrophin (hCG) level and endometrial thickness to the assessed accuracy. Methods We reviewed data from January 2009 to December 2014 of diagnostic curettages from women with suspected ectopic pregnancies sent for frozen section examination at a medical center. A frozen section diagnosis was considered accurate if it concurred with the final pathologic diagnosis. Results Of 106 frozen section studies, the diagnosis was accurate in 94 (88.7%). Of 79 specimens interpreted as negative on frozen sections (no products of conception noted), 9 (11.4%) were positive on final pathologic review. Three of the 27 (11.1%) specimens interpreted as positive by a frozen section failed to demonstrate products of conception on a final pathologic section. The sensitivity of frozen sections in the diagnosis of ectopic pregnancy was 72.7%, specificity 95.9%, positive predictive value 88.9%, negative predictive value 88.6%, and accuracy 88.6%. A statically significant correlation was found between β-hCG level and high accuracy of the frozen section technique (p< 0.001). No correlation was found between endometrial thickness and the accuracy of the frozen section technique. Conclusion The accuracy of frozen section examination was high and was found to correlate with β-hCG level, but not with endometrial thickness.

Pregnancy of Unknown Location: The Value of Frozen Section Analysis and Its Relation to Beta-hCG Levels and Endometrial Thickness.

OBJECTIVE: Frozen section examination is a rapid method for identifying products of conception in endometrial curetting, yet its accuracy is inconclusive. The purposes of this study is to determine the accuracy of frozen section analysis of endometrial curetting in pregnancies of unknown location, and to verify the relation of ß-human chorionic gonadotrophin (hCG) level and endometrial thickness to the assessed accuracy. METHODS: We reviewed data from January 2009 to December 2014 of diagnostic curettages from women with suspected ectopic pregnancies sent for frozen section examination at a medical center. A frozen section diagnosis was considered accurate if it concurred with the final pathologic diagnosis. RESULTS: Of 106 frozen section studies, the diagnosis was accurate in 94 (88.7%). Of 79 specimens interpreted as negative on frozen sections (no products of conception noted), 9 (11.4%) were positive on final pathologic review. Three of the 27 (11.1%) specimens interpreted as positive by a frozen section failed to demonstrate products of conception on a final pathologic section. The sensitivity of frozen sections in the diagnosis of ectopic pregnancy was 72.7%, specificity 95.9%, positive predictive value 88.9%, negative predictive value 88.6%, and accuracy 88.6%. A statically significant correlation was found between ß-hCG level and high accuracy of the frozen section technique (p < 0.001). No correlation was found between endometrial thickness and the accuracy of the frozen section technique. CONCLUSION: The accuracy of frozen section examination was high and was found to correlate with ß-hCG level, but not with endometrial thickness.

Symptomatic pelvic accessory spleen in a female adolescent: Case report.

Accessory spleens are congenital foci of healthy splenic tissue that are separate from the main body of the spleen. They occur in 10-30% of individuals; a wandering accessory spleen located in the pelvis is uncommon. Most patients are asymptomatic. We describe the case of a female adolescent presenting with acute abdominal pain who had a pelvic accessory spleen that mimicked an adnexal mass. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:600-602, 2017.

Early versus late misoprostol administration after mifepristone for medical abortion.

PURPOSE: To evaluate the successful medical termination of pregnancy comparing two regimens: misoprostol 2 or 48 h after mifepristone administration. DESIGN: Prospective randomized study. SETTING: Department of Obstetrics and Gynecology. SAMPLE: One hundred pregnant women admitted for medical termination of pregnancy were enrolled; no pregnancies were over 55 days gestational age. METHODS: All subjects were randomly assigned for misoprostol administration either 2 or 48 h after mifepristone. All participants underwent transvaginal ultrasound examination for uterine contents 48 h and 3 weeks after mifepristone. MAIN OUTCOME MEASURE: Procedure failure, defined as the presence of fetal heart activity, presence of a gestational sac, or a need for uterine curettage after misoprostol administration. RESULTS: Each group consisted of 50 women. Fetal heart activity was significantly more frequent after 48 h in the 2-h interval group (10/50) than in the 48-h interval group (0/50) (p = 0.002). Three weeks after misoprostol administration, fetal heart activity was present in 4/50 (8 %) in the 2-h interval group (p = 0.118) and none of the 48-h interval group. At 48 h residual tissue was present in 13/50 (26 %) and 5/50 (10 %) in the 2 and 48-h interval groups, respectively (p = 0.031); this was reduced to 12/50 (24 %) compared to 5/50 (10 %) in the two groups, respectively (p = 0.054) after 3 weeks. CONCLUSIONS: Successful medical termination of pregnancy can be achieved using misoprostol administration 2 h after mifepristone in 76 % of cases. However, this regimen is not recommended as it is significantly inferior to the traditional 48-h interval regimen.

Prediction of abortion using three-dimensional ultrasound volumetry of the gestational sac and the amniotic sac in threatened abortion.

PURPOSE: To determine whether gestational sac volume (GSV) or amniotic sac volume (ASV) and/or the difference between them can predict abortion in women with first-trimester threatened abortion. METHODS: Ninety patients between 6 and 12 weeks of gestation presenting with vaginal bleeding were studied. Seventy-six delivered after 24 weeks of gestation (group A) and 14 aborted before 20 weeks of gestation (group B). All patients had a singleton viable pregnancy demonstrated by transvaginal ultrasound. Gestational sac and amniotic sac volumes were measured in all the patients using three-dimensional transvaginal ultrasound with Virtual Organ Computer-aided Analysis software, and the gestational sac volume - amniotic sac volume (GSV - ASV) was calculated. RESULTS: The groups did not differ in terms of age, parity, number of previous abortions, or term deliveries. The GSV (group A: mean 32.0 ± 27.7 cm(3) ; group B: 26.7 ± 29.1 cm(3) ) and the ASV (group A: 21.1 ± 25.5 cm(3) ; group B: 20.6 ± 26.0 cm(3) ) were not statistically different, while the GSV - ASV was significantly smaller in group B (aborting before week 20) (group A: 10.9 ± 10.9 cm(3) ; group B: 6.1 ± 8.6 cm(3) ; p < 0.05). Using receiver operator curves, the area under the curve for predicting normal pregnancy outcome of the GSV - ASV measurement was 0.654. When the GSV - ASV was 1.8 cm(3) or less, abortion was predicted with 84% sensitivity and 43% specificity. CONCLUSIONS: The measurement of the GSV and the ASV are not good predictors of abortion in patients with first-trimester vaginal bleeding, whereas the use of the GSV - ASV may be helpful in predicting the outcome of pregnancy.

The effect of parity and gravidity on the outcome of medical termination of pregnancy.

BACKGROUND: Previous pregnancies may influence the success of medical termination of pregnancy. OBJECTIVES: To determine the effect of parity and gravidity on the successful termination of pregnancy using mifepristone and misoprostol. METHODS: The medical files of all patients attending a department of obstetrics and gynecology during the years 2006 and 2007 for the purpose of medical termination of pregnancy at < or = 49 days of gestation were analyze retrospectively. The medical history, previous pregnancies and deliveries were recorded. Mifepristone was administered orally followed by 400 mg of misoprostol 48 hours later. A second dose of misoprostol was offered 2 weeks later if uterine content thickness was more than 15 mm. Then, after 24 hours, if uterine content thickness was more than 15 mm the uterus was evacuated by dilation and curettage. RESULTS: Of 403 women, 349 (86.6%) aborted following the basic regime; 207 (51.4%) (group A) were primiparous while 196 (48.6%) (group B) had at least one prior pregnancy. Uterine curettage was performed in 17 patients (8.2%) in group A and in 37 (18.9%) in group B (P = 0.002). When patients with a history of a previous abortion were excluded from group B, 32 of 143 (22.4%) required curettage (P < 0.001). When patients without a history of previous cesarean section were excluded, 10 of 52 (19.2%) underwent curettage (P = 0.038). CONCLUSIONS: Previous pregnancies negatively affect the success of medical termination of pregnancy, especially in women with a previous term pregnancy. This information is important when counseling women about the method of pregnancy termination.

Early pregnancy failure: factors affecting successful medical treatment.

BACKGROUND: The results of medical treatment for early pregnancy failure are conflicting. OBJECTIVES: To determine whether gestational sac volume measurement as well as other variables can predict the success rate of medical treatment for early pregnancy failure. METHODS: The study group comprised 81 women diagnosed with missed abortion or anembryonic pregnancy who consented to medical treatment. Demographic data were collected and beta-human chorionic gonadotropin level was documented. Crown-rump length and the sac volume were measured using transvaginal ultrasound. TVU was performed 12-24 hours after intravaginal administration of 800 micro g misoprostol. If the thickness of the uterine cavity was less than 30 mm, the women were discharged. If the sac was still intact or the thickness of the uterine cavity exceeded 30 mm, they were offered an additional dosage of intravaginal misoprostol or surgical uterine evacuation. RESULTS: Medical treatment successfully terminated 32 pregnancies (39.5%), 30 after one dose of misoprostol and 2 after two doses (group A); 49 underwent surgical evacuation (group B), 47 following one dose of misoprostol and 2 following two doses. There were no significant differences between the groups in age and gestational week. Gestational sac volume did not differ between groups A and B (10.03 and 11.98 ml respectively, P = 0.283). Parity (0.87 and 1.43, P = 0.015), previous pregnancies (2.38 and 2.88, P = 0.037), and betahCG concentration (6961 and 28,748 mlU, P = 0.013) differed significantly between the groups. CONCLUSIONS: Gestational sac volume is not a predictor of successful medical treatment for early pregnancy failure. Previous pregnancies and deliveries and higher betahCG concentration negatively affect the success rate of medical treatment.

Gestational sac volume in missed abortion and anembryonic pregnancy compared to normal pregnancy.

PURPOSE: To compare gestational sac (GS) volume (GSV) between normal pregnancies and missed abortions and anembryonic pregnancies and to determine at what gestational age differences in GS volume become evident. METHODS.: GSV in missed abortion and anembryonic pregnancy were measured using three-dimensional ultrasound and the results were compared with GSV in normal pregnancies. Pregnancies between 6 and 12(+6) gestational weeks of age according to last menstrual period were included in normal pregnancies, missed abortions, and anembryonic pregnancies. RESULTS: There were 141 normal pregnancies and 82 missed or anembryonic abortions. GSV was significantly larger in normal pregnancies than in missed or anembryonic abortion: 27.51 + or - 25.25 cm(3) and 8.04 + or - 10.54 cm(3), respectively (p < 0.001). When stratified by weeks, statistically significant differences were found beginning at 7 weeks, while GSV measurements were not significantly different between the normal and abnormal pregnancies from 6 to 6(+6) weeks. CONCLUSION: GSV in missed abortion and anembryonic pregnancies is significantly smaller than in normal pregnancies, starting at 7 weeks of gestational age. This finding may be helpful in the diagnosis of missed abortion or anembryonic pregnancies in selected cases.

[Vestibulodynia--the Israeli experience].

The cause of vestibulitis, currently known as vestibulodynia, is still an enigma. Among those attempting to decipher the puzzle, Israeli researchers are well represented. This article reviews the developments in terminology, etiology, treatment, and research directions, with an emphasis on the role of IsraeLi research. Forty-four articles, covering a range of aspects of vestibulodynia, are testimony to the commendable contribution of Israeli research to the understanding of this disease. For example, the finding of mast cell proLiferation and degranulation, enhanced heparanase expression, and the resultant increase and penetration of nerve fibers into the epithelial emanates from Israel. Furthermore, an Israeli first proposed the new name, vestibulodynia. Implemented in the 1980s, immediately after its initiation in the United States, surgical treatment and research in Israel is at the forefront in the world. Israeli teams investigating the effectiveness of surgical treatment conclude that perineoplasty is more successful than any other treatment. Nonetheless, with 57% complete response, and 89% improvement, surgery does not cure all those suffering from vestibulodynia.

[Reforming the ambulatory care system--attitudes of patients and staff members].

BACKGROUND AND OBJECTIVES: The study aimed to examine the attitudes of patients and staff towards the reform the ambulatory healthcare by moving services from the hospital to the community. METHODOLOGY: A cross-sectional study using a questionnaire was conducted during 2001 to examine the attitudes of patients and staff. The study took place in eight community clinics and eight hospital-based clinics and units where surgical activity took place. Patients' and staff questionnaires were completed in each clinic, researching procedures that until recently had been performed only in hospitals and were then transferred to community clinics. One procedure was chosen for each clinic. FINDINGS: A total of 1000 patients and 78 staff members were interviewed. Most patients expressed their satisfaction with the treatment location to which they were assigned. Prior acquaintance with the physician treating the patients was a factor associated with the preference of the treatment location. Many patients view the hospital as an institution where complications can be better handled than in the community clinic. There is a difference between the attitudes of patients and staff members in the perception of the weight of certain factors on the choice of treatment location. CONCLUSION: Certain variables are significant to the patients in their choice of treatment location. There are differences between the attitudes of staff members and patients, emphasizing the importance of studying the attitude of the patients themselves before choosing the location of treatment.