E. Kirk

Pregnancy of unknown location: a consensus statement of nomenclature, definitions, and outcome

OBJECTIVE To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of population, target disease, and final outcome. DESIGN A review of literature and a series of collaborative international meetings were used to develop a consensus for definitions and final outcomes of women initially diagnosed with a PUL. RESULT(S) Global differences were noted in populations studied and in the definitions of outcomes. We propose to define initial ultrasound classification of findings into five categories: definite ectopic pregnancy (EP), probable EP, PUL, probable intrauterine pregnancy (IUP), and definite IUP. Patients with a PUL should be followed and final outcomes should be categorized as visualized EP, visualized IUP, spontaneously resolved PUL, and persisting PUL. Those with the transient condition of a persisting PUL should ultimately be classified as nonvisualized EP, treated persistent PUL, resolved persistent PUL, or histologic IUP. These specific categories can be used to characterize the natural history or location (intrauterine vs. extrauterine) of any early gestation where the initial location is unknown. CONCLUSION(S) Careful definition of populations and classification of outcomes should optimize objective interpretation of research, allow objective assessment of future reproductive prognosis, and hopefully lead to improved clinical care of women initially identified to have a PUL.

Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location

Various serum human chorionic gonadotropin (hCG) discriminatory zones are currently used for evaluating the likelihood of an ectopic pregnancy in women classified as having a pregnancy of unknown location (PUL) following a transvaginal ultrasound examination. We evaluated the diagnostic accuracy of discriminatory zones for serum hCG levels of > 1000 IU/L, 1500 IU/L and 2000 IU/L for the detection of ectopic pregnancy in such women.

Diagnosis and management of ectopic pregnancy.

An ectopic pregnancy occurs when a fertilised ovum implants outside the normal uterine cavity.1,–,3 It is a common cause of morbidity and occasionally of mortality in women of reproductive age. The aetiology of ectopic pregnancy remains uncertain although a number of risk factors have been identified.4 Its diagnosis can be difficult. In current practice, in developed countries, diagnosis relies on a combination of ultrasound scanning and serial serum beta-human chorionic gonadotrophin (β-hCG) measurements.5 Ectopic pregnancy is one of the few medical conditions that can be managed expectantly, medically or surgically.1 3 6 In the developed world, between 1% and 2% of all reported pregnancies are ectopic pregnancies (comparable to the incidence of spontaneous twin pregnancy).7 The incidence is thought to be higher in developing countries, but specific numbers are unknown. Although the incidence in the developed world has remained relatively static in recent years, between 1972 and 1992 there was an estimated six-fold rise in the incidence of ectopic pregnancy.8 This increase was attributed to three factors: an increase in risk factors such as pelvic inflammatory disease and smoking in women of reproductive age, the increased use of assisted reproductive technology (ART) and increased awareness of the condition, facilitated by the development of specialised early pregnancy units (EPUs). In the UK, ectopic pregnancy remains the leading cause of pregnancy-related first trimester death (0.35/1000 ectopic pregnancies).3 6 9 However, in the developing world it has been estimated that 10% of women admitted to hospital with a diagnosis of ectopic pregnancy ultimately die from the condition.10 Ectopic pregnancy is a considerable cause of maternal morbidity, causing acute symptoms such as pelvic pain and vaginal bleeding and long-term problems such as infertility.3 Short- and long-term consequences of ectopic pregnancy on …

Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements: a multicenter observational study

There is significant variation in cut‐off values for mean gestational sac diameter (MSD) and embryo crown–rump length (CRL) used to define miscarriage, values suggested in the literature ranging from 13 to 25 mm for MSD and from 3 to 8 mm for CRL. We aimed to define the false‐positive rate (FPR) for the diagnosis of miscarriage associated with different CRL and MSD measurements with or without a yolk sac in a large study population of patients attending early pregnancy clinics. We also aimed to define cut‐off values for CRL and MSD that, on the basis of a single measurement, can definitively diagnose a miscarriage and so exclude possible inadvertent termination of pregnancy.

The conservative management of cervical ectopic pregnancies.

To evaluate the role of conservative management in the treatment of cervical ectopic pregnancies.

Prediction of ectopic pregnancy in women with a pregnancy of unknown location

We have previously published on the use of mathematical Model M1 to predict ectopic pregnancy in women with no signs of intra‐ or extrauterine pregnancy. The aim of this study was to improve on the performance of this model for the detection of developing ectopic pregnancies in women with pregnancies of unknown location (PULs). We therefore generated and evaluated a new logistic regression model from simple hormonal data and compared it with Model M1.

Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location

BACKGROUND A diagnosis of ectopic pregnancy (EP) is primarily achieved using transvaginal ultrasonography (TVS). Pregnancy of unknown location (PUL) is the term used to categorize a pregnancy in a woman with a positive pregnancy test when no pregnancy has been visualized using TVS. This review appraises current tools for the diagnosis of EP, describes the diagnostic criteria for non-tubal EP and reviews the literature on the clinical management of PUL. METHODS We performed a targeted search using the PubMed database. All articles published in the English language from January 1984 to March 2013 were screened for eligibility. RESULTS Using TVS to diagnose EP is highly sensitive (87-99%) and specific (94-99.9%). Variations exist in the criteria used for ultrasound diagnosis. Studies report that between 5 and 42% of women seen for ultrasound assessment with a positive pregnancy test have a PUL. For PUL, measurements of serum human chorionic gonadotrophin (hCG) and progesterone are used to predict pregnancy viability and therefore give an indication of the risk of an EP. Only 6-20% of PUL are subsequently diagnosed with EP. Non-tubal EPs are relatively uncommon, difficult to diagnose and result in disproportionate morbidity and mortality. CONCLUSIONS Access to expertise and equipment for high-quality TVS means the majority of women with EP in developed countries can be diagnosed rapidly and accurately. Identifying PUL, which are low risk and therefore requiring less follow-up, finding better serum markers for EP and safely identifying women who do not require intervention for EP are the current diagnostic challenges.

The accuracy of first trimester ultrasound in the diagnosis of hydatidiform mole

Previous studies have examined ultrasound findings in histopathologically confirmed cases of hydatidiform mole. The aim of this study was to assess the first‐trimester ultrasonographic findings in all women suspected of having hydatidiform mole on ultrasound and those subsequently diagnosed with hydatidiform mole after histological examination of removed products of conception after surgical evacuation of the uterus. The aim was to obtain a true sensitivity and positive predictive value for ultrasound in the diagnosis of hydatidiform mole.

General obstetrics: Failing pregnancies of unknown location: a prospective evaluation of the human chorionic gonadotrophin ratio

Objective  To assess the performance of the human chorionic gonadotrophin (hCG) ratio (hCG 48 hours/hCG 0 hour) to predict spontaneous resolution of pregnancies of unknown location (PUL).

Evidence of early first‐trimester growth restriction in pregnancies that subsequently end in miscarriage

Objectives  To examine whether viable early pregnancies that subsequently end in miscarriage exhibit evidence of first‐trimester growth restriction.