ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

The incidence of ectopic pregnancy in the United States has been increasing steadily during the past three decades from 4.5 per 1,000 pregnancies in 1970 to 19.7 per 1,000 pregnancies in 1992.1This epidemic continues in other western countries; for example, Norway had an increase from 12.5 to 18.0 per 1,000 reported pregnancies during 1979 to 1993.2Yet other countries, such as France and Sweden, are reporting a stabilization of the ectopic pregnancy rate.In the United States, the prevalence of risk factors for ectopic pregnancy are increasing, accounting, in part, for the increased ectopic pregnancy incidence.1Further, the increased incidence of ectopic pregnancy may be the result of earlier diagnosis, with the use of sensitive pregnancy tests and transvaginal ultrasound detecting some ectopic pregnancies that in the past may have resolved spontaneously before diagnosis.3Despite the increased incidence, maternal deaths due to ectopic pregnancy are declining as a result of early diagnosis and therapy. Between 1979 and 1986, 13% of maternal deaths were secondary to ectopic pregnancy4; by 1992, this figure had decreased to 9%.1Yet, ectopic pregnancies continue to be the leading cause of maternal death in the first trimester, 90% as a result of hemorrhage.4

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

The diagnosis of ectopic pregnancy has undergone a major evolution in the past two decades. The introduction of sensitive β subunit human chorionic gonadotropin (β-hCG) assays and high resolution transvaginal sonography has enabled precise and early diagnosis of ectopic pregnancy before the development of critical signs and symptoms.Historically, clinicians managed ectopic pregnancy by excision via laparotomy. The suspicion for ectopic pregnancy resulting from the diagnostic work-up had to be strong enough to justify performing a major operation. The desire for conservative management of ectopic pregnancy and oviduct preservation made the diagnosis of unruptured gestational mass essential. The introduction of laparoscopy gave the clinician a powerful tool that enabled the making of an accurate diagnosis without a laparotomy skin incision. Later, the development of operative laparoscopy added a treatment ability to this diagnostic procedure. With the recent advent of medical treatment for ectopic pregnancy, an accurate and early diagnosis of ectopic pregnancy has become even more important. Although a surgical approach gives the clinician an opportunity to confirm the diagnosis, the medical therapy does not provide this verification, and, therefore, the diagnostic process must be thorough. In the past, many patients who were taken to the operating room with a diagnosis of presumptive ectopic pregnancy were found to have other benign conditions mimicking an ectopic pregnancy and frequently not requiring surgical treatment.1A modern and more precise diagnostic process may limit or even eliminate such unnecessary surgical procedures.Thanks to a more reliable and earlier diagnosis of ectopic pregnancy, the initial presentation of a woman with this condition has changed during the recent years. Fewer patients develop acute abdomen and hypovolemia resulting from a ruptured and acutely bleeding ectopic implantation site. More prompt diagnosis and earlier intervention has led to a dramatic decrease in mortality from ectopic pregnancy. The population of women at high risk for developing ectopic pregnancy can be identified and prospectively screened for the location of implantation site early after conception.2The advancement in the field of assisted reproductive technology (ART) has brought some new challenges to the diagnosis of ectopic pregnancy. Multiple implantations resulting from the transferring of multiple embryos obtained through fertilization in vitro may lead to more frequent heterotopic pregnancies (1% of all pregnancies resulting from in vitro fertilization), which are rare in spontaneous, unstimulated reproductive cycles (1:5,000 pregnancies).The natural history of ectopic pregnancy may vary. In some cases of trophoblast in regression, an early ectopic pregnancy may be in the process of spontaneous resolution, and no intervention is necessary. Other women who may be asymptomatic and clinically stable with no signs of intra-abdominal bleeding and no apparent adnexal mass may experience a sudden rupture of a small gestational extra-uterine mass and quickly develop hypovolemic shock. These different dynamics in the development of an ectopic pregnancy may confuse the clinician, who needs to remain cautious and critical during the diagnostic process.Conservative surgical management of ectopic pregnancy as well as medical therapy may not eradicate the trophoblastic tissue entirely. The remaining trophoblast may preserve its viability and continue to grow, leading to persistent ectopic pregnancy. Although the incidence of persistent ectopic pregnancy is low, ranging from 2-20% of conservatively treated women, it may result in sudden hemorrhage and tubal rupture in 24% of the cases.3

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Recent reports affirm that ectopic pregnancy is evolving into a medical disease. This evolution is driven first by increasingly reliable nonsurgical diagnosis. Algorithms using combinations of hormone measurements and gynecologic ultrasound facilitate timely diagnosis and eliminate need for surgical visualization. Second, the evolution is driven by lower costs. In the United States, national costs for diagnosis and management of ectopic pregnancy in 1990 was estimated at 1.1 billion dollars. Third, and finally, medical therapy virtually eliminates surgical complications from treatment.Systemic methotrexate is emerging as the standard medical regimen in the United States and Europe. It is the principal medical therapy discussed in this chapter.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

The first successful surgical treatment of ectopic pregnancy (EP) was described in 1883 by Tait.1He performed salpingectomy on four women with ectopic pregnancy, and they all survived, an event that was extraordinary then. In 1973, Shapiro and Adler described treatment of ectopic pregnancy by laparoscopy, and today it is the standard surgical treatment of ectopic pregnancy. The key for a successful laparoscopic treatment of ectopic pregnancy is early diagnosis. This can be achieved by serial serum human chorionic gonadotropin (β-hCG) measurement and by transvaginal ultrasound examination. Once the diagnosis of ectopic pregnancy is made, the mode of treatment can be tailored accordingly.The sites of ectopic implantation can be divided into tubal and extratubal. Tubal pregnancy can be ampullary, isthmic, fimbrial, or interstitial. Extratubal ectopic pregnancies include abdominal, ovarian, and cervical pregnancy.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Several studies have now shown that non-invasive diagnostic algorithms involving the use of highly sensitive and specific immunoassays for human chorionic gonadotrophin (hCG) and high resolution vaginal ultrasound are as accurate as laparoscopy in the diagnosis of ectopic pregnancy.1,2These algorithms also have proved fruitful in making the diagnosis early in the course of the disease before tubal rupture has occurred. In fact, intervention now usually occurs before rupture in greater than 80% of cases. Most importantly, patients diagnosed before tubal rupture are candidates for alternative treatment options besides surgery, including systemic medical management or local ultrasound-directed injection with a number of tropholytic (methotrexate, hyperosmolar glucose, and potassium chloride) agents. These alternative options are attractive because of their ability to avoid the risks of surgery and general anesthesia while also reducing health care costs to the patient.3Systemic medical treatment has been discussed elsewhere in this volume, and therefore the remainder of this article will focus on reports in the literature to demonstrate the technique and potential use of transvaginal ultrasound-guided salpingocentesis as a treatment for unruptured ectopic pregnancy.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Ectopic pregnancy was frequently fatal before the advent of surgical intervention. For many years, salpingectomy was the standard approach. Later, in an effort to preserve future fertility, salpingostomy was introduced in cases without extensive tubal damage. More recently, medical management of ectopic pregnancy with methotrexate has proven efficacious in carefully selected unruptured ectopic pregnancies. Often forgotten, however, is that before the advent of surgical therapy it was noted that ectopic pregnancy was not uniformly fatal and that some patients had spontaneous resolution of the ectopic gestation, either through spontaneous regression or tubal abortion. This fact led certain physicians to attempt purposeful expectant management of ectopic pregnancies. Their studies have helped define which patients are likely to benefit from this strategy. We review the published studies that describe the expectant management of ectopic pregnancy and provide guidelines to assist clinicians in choosing this approach to treatment.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Maternal viral and protozoan infections contribute enormously to childhood morbidity. TORCH infections include infections associated withToxoplasma,Other organisms (Parvovirus, human immunodeficiency virus, Epstein-Barr virus, herpesviruses 6 and 8, varicella, syphilis, enteroviruses),Rubella,Cytomegalovirus (CMV), andHepatitis. Despite the recent emphasis in the screening, antibiotic prophylaxis, and management of early-onset group B streptococcal sepsis of the newborn (GBS sepsis), many neonates and children yearly experience the consequences of classic perinatal infections(Table 1). These infections need the same attention as GBS sepsis. The other TORCH infections such as rubella, varicella, Epstien-Barr virus, herpesvirus 6 and 8, and hepatitis B (HBV) will receive little discussion in the remainder of this article as their diagnosis and management is clear and highly efficacious.TABLE 1. Perinatal Infections and Newborn/Childhood DiseaseThe reasons for the lack of focus on TORCH infections are speculative and include few maternal symptoms of infection, limited and expensive diagnostic tools for fetal infection, lack of effective therapy in the treatment of these infections, and the late occurrence of symptoms in children (chorioretinitis, deafness, mental deficiencies). In contrast, GBS sepsis can be prevented through risk identification, screening for maternal lower genital tract GBS carriage, and relatively inexpensive antibiotic prophylaxis. The incidence of subclinical infection in the mother is >95% with CMV, toxoplasmosis, hepatitis B, Parvovirus B19, Epstein-Barr virus, herpesvirus type six and 8, group B streptococcus, and HIV; and 50-75% with varicella, herpes simplex virus (HSV), and syphilis. How does the obstetrician identify the fetus at risk for perinatal infection from the latter three organisms?Currently, prenatal patients are routinely screened for rubella, hepatitis B, syphilis, GBS, and HIV. These infections have clear measures to prevent or limit perinatal infection by vaccine, immunoglobulins, or antibiotics. Varicella soon may join the latter group by virtue of a newly developed, effective vaccine. The efficacy of these therapies exceeds 90%. In the United States, routine screening for other TORCH infections does not seem to be justified based on cost-benefit analysis (see Chapter by Mittendorf). The central issue related to prenatal diagnosis is the inability to diagnose maternal infection. The obstetrician must base his or her laboratory evaluation on the presence of epidemiologic risk factors or on the presence of clinical findings.Table 2describes epidemiologic and clinical risk factors that increase the likelihood of perinatal infection.TABLE 2. Epideminologic and Clinical Risk Factors for Perinatal InfectionOccupational exposure includes work in the following settings: chronic care facilities, day care facilities, neonatal intensive care units, renal dialysis units, and elementary schools (Parvovirus B19).The major benefit of risk identification that the prevalence of infection will be higher in the tested population. This can have a tremendous effect on the accuracy of the test. For example, given a test that is 90% sensitive and 95% specific, the incidence of false-positive tests is 98% when the prevalence is 1 per 1,000, 85% when the incidence is 1 per 100, and 31% when the incidence is 1 per 10. Because evidence of fetal infection on initial screening raises the specter of complicated and dangerous fetal diagnosis (cordocentesis) or elective abortion, testing accuracy is paramount to reduce the number of fetuses who are unnecessarily injured by such techniques. A corollary is that clinicians must carefully educate the pregnant woman before and after a screening test.The purpose of this article is not to describe the accuracy of testing in the setting of a world-class laboratory, but to describe the accuracy of tests provided by the major clinical laboratories in the United States. Major commercial laboratories include LabCorp, SmithKline-Beecham, and Specialty Laboratories. The efficiency of the tests and the laboratories determines further testing or intervention. As argument is developed, the most prudent action may be not to start with routine screening in the first place.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID