Moshe Bustan

Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: experience with 840 cases

OBJECTIVE To evaluate the efficacy of transvaginal sonography and serum beta-hCG levels as diagnostic tools for deciding whether to perform operative laparoscopy in the treatment of presumed ectopic pregnancy (EP). DESIGN A prospective protocol for the evaluation and treatment of women with presumed EP. SETTING Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel. PATIENT(S) Eight hundred forty women with presumed EP who were seen in our emergency department from January 1988 through December 1995. INTERVENTION(S) On the basis of specific sonographic signs and beta-hCG levels, we performed immediate operative laparoscopy in patients with demonstrable extrauterine fetal heart activity or >100 mL of fluid in the pelvic cavity. We followed up all other patients, using defined criteria for laparoscopic intervention. MAIN OUTCOME MEASURE(S) The accuracy of transvaginal sonography in predicting EP was evaluated as part of the described protocol. RESULT(S) Overall, 380 patients were found to have EP. Of these, 331 were identified positively by transvaginal sonography and 49 were not. In 27 of 358 laparoscopies, no EP was found. The sensitivity of transvaginal sonography for the prediction of EP was 87% and the specificity was 94%. The positive and negative predictive values were 92.5% and 90%, respectively. CONCLUSION(S) In this protocol, which invariably captured the true location of the products of conception, using transvaginal sonography as the primary modality in the evaluation of patients with presumed EP resulted in the use of laparoscopy mainly as a treatment tool. This approach is both safe and economical.

Spontaneous resolution of ectopic tubal pregnancy: natural history

OBJECTIVE To determine the characteristics and long-term outcome of women succeeding or failing expectant management of ectopic pregnancy (EP). DESIGN Prospective, defined protocol. SETTING University-affiliated gynecology department. PATIENTS We used a protocol that selected women with laparoscopic confirmed ectopic tubal pregnancy and declining plasma hCG values. Over a 5-year period, 60 women representing 20.1% of EPs fulfilled the inclusion criteria. Women were followed with serial hCG testing and transvaginal ultrasound. MAIN OUTCOME MEASURE Success or failure of expectant management. RESULTS Expectant management was successful in 28 (47.7%) of the patients. Thirty-two (53.3%) failed expectant management, and a treatment procedure was required. There was no difference in the resultant ipsilateral tubal patency or 1-year fertility rates of those women succeeding or failing expectant management. Analysis showed that in the face of declining values and with a starting hCG > 2,000 mIU/mL (conversion to SI unit, 1.00), 93.3% failed expectant management, whereas < 2,000 mIU/mL, 60.0% succeeded. CONCLUSION We conclude that expectant management should be offered as a treatment option only in those women fulfilling the criteria for a good prognosis.

Pharmacokinetics of methotrexate after local tubal injection for conservative treatment of ectopic pregnancy

Methotrexate peak level after intratubal injection was found to be significantly lower than the accepted toxic level. After IM injection, MTX peak level and the AUC were found to be similar to the levels observed after intratubal injection. The advantage of tubal injection over IM injection is challenged.

Limited role for intratubal methotrexate treatment of ectopic pregnancy

OBJECTIVE To test the effectiveness of laparoscopic intratubal methotrexate (MTX) injection or salpingostomy in the treatment of ectopic pregnancy (EP). DESIGN Prospective predefined protocol. SETTING Department of Obstetrics and Gynecology of a university-affiliated hospital. PATIENTS AND INTERVENTIONS Between January 1988 and December 1993, we treated 342 women with EP, of which 99 were treated by either laparoscopic salpingostomy (n = 55) or intratubal MTX injection (n = 44). MAIN OUTCOME MEASURES The success and failure rates were calculated for each treatment protocol. Also analyzed were subsequent tubal patency and fertility rates. RESULTS Salpingostomy was successful in 51 of 55 patients (92.7%), whereas intratubal MTX injection was successful in only 27 of 44 women (61.4%). Methotrexate injection particularly was unsuccessful if the initial hCG was > 2,000 mIU/mL (conversion factor to SI unit, 1.00) or the size of the tubal mass was > 2.0 cm as measured during laparoscopy. There was no difference in the subsequent tubal patency rates of fertility rates between women undergoing MTX injection or salpingostomy. CONCLUSIONS These results suggest that salpingostomy is effective in the treatment of EP. Methotrexate injection failed in more patients despite preferential selection criteria, suggesting that its use should be limited to the subgroup of women with initial hCG < 2,000 mIU/mL and size at laparoscopy < 2.0 cm.

Laparoscopic subtotal hysterectomy and bilateral adnexectomy in a child with congenital adrenal hyperplasia

OBJECTIVE To report the results of a subtotal hysterectomy and bilateral adnexectomy in a child with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. DESIGN Case report. SETTING Gynecology department, Afula, Israel. PATIENT(S) An 11-year-old child with a female genotype and saltwasting type congenital adrenal hyperplasia who was being raised as a boy. INTERVENTION(S) Laparoscopic subtotal hysterectomy and bilateral salpingo-oophorectomy were performed. MAIN OUTCOME MEASURE(S) Surgical efficiency, operating time, recovery, and aesthetic result. RESULT(S) The procedure was performed without complications in 26 minutes, and the child was dismissed the following day. Three 5-mL abdominal incisions were required. CONCLUSION(S) Laparoscopic subtotal hysterectomy and bilateral adnexectomy can be safely performed in children and is the procedure of choice in the rare cases in which it is indicated.