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In Ohio, a 33-year old woman who had never had an ectopic pregnancy presented at an emergency facility not physically attached to a hospital with abdominal pain over 24 hours which had become more intense during the preceding 4 hours. She did not have vaginal bleeding, diarrhea, vomiting, or pain while urinating. 2 weeks earlier she had a voluntary intrauterine abortion at 8 weeks' gestation. She had intercourse 1 week before coming to the emergency facility. She had widespread tenderness in her abdomen, especially in the lower areas. Blood cell studies suggested an infection. The attending physician presumed her to have pelvic inflammatory disease (PID) as a result of either sexual intercourse or the elective abortion. The physician called for a urinary beta human chorionic gonadotropin test to determine whether placental tissue remained in the uterus. It was positive. 60 minutes after admission, the supine patient's pain increased and her blood pressure dropped to 80/50 mm Hg from 100/60 mm Hg at admission. After administering Ringer's solution, the health team sat her up and she fainted. A repeat cell count indicated sepsis. Her blood pressure decreased to 60 by Doppler and the physician continued to give her fluids and began dopamine. After the team stabilized her, they transferred her to a hospital. Her private physician examined her and then began surgery. The physician found a tubal pregnancy and removed the affected tube and ovary. She recuperated completely. Combined intrauterine and extrauterine pregnancy occurs once in every 30,000 cases. Previous PID, use of ovulation inducing medication, and in vitro fertilization with embryo transfer increases the likelihood of this type of pregnancy occurring. Physicians should consider this possibility if a woman has any of these histories and a combination of abdominal pain, adnexal mass with pain and tenderness, peritoneal irritation, and an enlarged uterus.
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PMID:Ruptured ectopic pregnancy in a patient with a recent intrauterine abortion. 157 Sep 21

5 major criteria are used to evaluate family planning methods: efficacy, both theoretical and practical; acceptability as measured by continuation of use; safety; reversibility; and cost, including the cost of treatment, follow-up, and screening for contraindications. Traditional family planning methods are mostly based on periodic abstinence during the presumed fertile period. The calendar, temperature, Billings or cervical mucus, and symptothermal methods are based on observation of different symptoms of ovulation and fertility. Their advantages are that they do not require intervention by health personnel, their costs of use are nil, and they are morally acceptable to some couples. Their efficacy is lower than that of other methods and they should be viewed as methods to space rather than limit births. The withdrawal method, also less effective, requires active cooperation by the male partner. Among mechanical methods, the use of condoms has increased recently because of the protection they offer against HIV infection and other sexually transmitted diseases. Their efficacy depends on correct use, regular use, and the quality of the condom. The Pearl index varies from 93099 per 100 woman-years. The diaphragm must be individually measured and should be used with spermicides. The Pearl index ranges from 85095 per 100 woman-years. Spermicides, generally either nonoxynol-9 or benzalkonium chloride, are surfactants that have a Pearl index of 83-97 per 100 woman-years. They are available as creams, jellies, foams, suppositories, tablets, or impregnated sponges. Most failures appear due to errors of utilization. The mechanism of action of the IUD is imperfectly understood, but it is known to prevent nidation of the fertilized egg. Copper devised have higher rates of efficacy and tolerance. Pearl indices range from 95-99.5. Contraindications include genital infection, uterine anomalies, valvular cardiopathy, and coagulation problems. The IUD is relatively contraindicated if there is history of ectopic pregnancy or upper genital tract infections. The combined oral contraceptive is the most widely utilized method in France. The Pearl index is nearly 100 in the absence of forgetting, vomiting, or drug interactions. The contraindications are basically those of estrogens: history of thrombosis, prolonged bedrest, hypertension, hyperlipidemia, hepatic disorders, hormonodependent cancers, or smoking after age 35. Progestin-only methods are available in 3 forms: low-dose pills which must be taken at the same time each day, higher-dosed progestins taken for 20 days each month, and injectable progestins providing contraception for 8-12 weeks. Postcoital contraception using OCs or IUDs is possible but not well known among women or physicians. The Neuwirth law authorizing use of contraception in France was passed in 1967. Amendments in 1974 improved access and provided for reimbursement for some methods, but some newer forms are not reimbursed.
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PMID:[Family planning. Objectives, measures, regulations, structures]. 185 35

The International Planned Parenthood Federation (IPPF) new statement on the diagnosis of pregnancy was drawn up in April 1990. A pregnancy diagnosis includes clinical evaluation of the woman's history, symptoms, physical examination, and pregnancy tests. Pregnancy symptoms may include amenorrhea, nausea, vomiting, enlargement and tenderness of the breasts, frequent urination, and changes in appetite and food and drink habits. If biochemical testing is not possible, a reliable clinical diagnosis of pregnancy cannot take place before 6-8 weeks. At this time, the clinician can observe cervical softening and uterine softening and enlargement if a woman is pregnant. If the uterine size does not match the length of amenorrhea, clinicians should suspect the following: earlier or later conception than indicated, ectopic pregnancy, incomplete or missed spontaneous abortion, twin gestation, hydatidiform mole, or other uterine anomaly. They should suspect ectopic pregnancy in women with smaller than expected uterine size when they have been sterilized or are using an IUD or are using low-dose progestogen-only pills or Norplant. They should refer women with smaller than expected uterine size who are experiencing bleeding and/or pain to a more sophisticated clinical facility, where an accurate diagnosis of and adequate treatment for ectopic pregnancy can be done. Biochemical pregnancy tests consist of antibodies that mark human chorionic gonadotropin (hCG) from a urine or serum sample. hCG levels increase beginning about 10 days after fertilization. The most convenient and inexpensive pregnancy test for clinics is the immunoassay test (slide test), which requires a urine or serum sample. It can provide reliable results a few days after the missed menstrual period. Clinicians should provide appropriate counseling regardless of whether the client wishes to continue or terminate the pregnancy.
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PMID:New IPPF statement on the diagnosis of pregnancy. 192 37

Risk factors for ectopic pregnancy include previous ectopic pregnancy, current intrauterine device use, prior fallopian tube surgery, previous pelvic inflammatory disease and a prior history of infertility. Abdominal pain is the most common symptom, followed by amenorrhea or vaginal bleeding, nausea, vomiting, syncope and dizziness. Referred shoulder pain following the onset of abdominal pain is characteristic of intraperitoneal bleeding and, in the appropriate clinical setting, strongly suggests a ruptured ectopic pregnancy. A coordinated evaluation includes measurement of serum human chorionic gonadotropin concentration and transabdominal or, preferably, transvaginal ultrasonography. Treatment is primarily by one of a variety of surgical techniques. Medical therapy with methotrexate or other drugs is currently under investigation.
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PMID:Management of ectopic pregnancy. 218 38

The authors report transvaginal puncture of ectopic pregnancy and instillation therapy under sonographic control in 10 cases. Only patients with an increase in beta-hCG levels were selected for treatment. In 9 cases, the authors instilled methotrexate and in 1 case, prostaglandin E2 (PGE2). A successful outcome was obtained in 8 cases, 7 having been treated with methotrexate and 1 treated with PGE2. conservative treatment failed in 2 patients. However, these patients were already in the 8th week of pregnancy. There were no side effects after methotrexate; the patient who received PGE2 experienced severe discomfort, vomiting, and cramps.
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PMID:Treatment of unruptured ectopic pregnancy by needling of sac and injection of methotrexate or PG E2 under transvaginal sonography control. Report of 10 cases. 281 65

Prior tubal sterilization should be regarded as a possible etiologic factor in the pathogenesis of ectopic pregnancy. The authors present the case of a 32-year-old woman, para 4, who presented to Kenyatta National Hospital in October 1985 with complaints of lower abdominal pain and vomiting. She had undergone tubal ligation in February 1985. Examination revealed a ruptured ectopic pregnancy in the lateral part of the left tube. There was active bleeding from the rupture. The right distal stump was intact, and the right proximal stump had no obvious defect. There was a corpus luteum in the left ovary. Ectopic gestation after tubal sterilization apparently occurs when there is recanalization and formation of a proximal tuboperitoneal fistula, allowing sperm passage and fertilization of the ovum in the peritoneal cavity, on the ovarian surface or within the ductal tubal lumen. Although the technical details of this patient's sterilization were not available, laparotomy indicated that a modified Pomeroy procedure using absorbable sutures had been performed. The failure rate for the Pomeroy procedure is estimated at 0.25-2%. Since the incidence of ectopic pregnancy following tubal sterilization is about 1 in 13 in some parts of the world, potential sterilization acceptors should be counseled about this complication and a diagnosis of ectopic gestation should be considered whenever a patient with a previous history of tubal ligation presents with signs or symptoms of pregnancy.
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PMID:Ruptured tubal pregnancy following tubal sterilization. 332 62

Tubal abortion is the term used when an intact, viable pregnancy is surgically removed during an operative intervention in an ectopic pregnancy. Tubal abortion can follow several courses: resorption of the products of conception; intraluminal extension with expulsion of gestational products; and perforation and rupture into the peritoneal cavity. Spontaneous resorption occurs with very early embryonic death, and is usually symptomless and undiagnosed. Such spontaneously regressing tubal pregnancies are more easily detected with today's more sensitive and refined diagnostic capabilities that have detected previously unsuspected tubal pregnancies. Intraluminal extension results in hemorrhage and expulsion of the gestational products into the tubal lumen, but terminology about this is unclear. If the ovum remains attached to the implantation site, the term incomplete tubal abortion should be used. If the ovum completely separates from the tubal wall and is expelled, it should be termed complete tubal abortion. Stringent pathologic criteria are used for the diagnosis of tubal abortion, and earlier diagnosis and management have led to a decrease in the percentage of ruptured tubal pregnancy. Clinical presentation of tubal abortion includes symptoms of colicky pain, nausea, vomiting, faintness, and signs of peritoneal irritation and shock. In the past, salpingectomy was the treatment of choice for tubal abortions, but conservative techniques can be used to preserve the tube, depending on factors such as the state of the tube, stage of the abortion, and degree of associated bleeding. The method chosen can affect fertility after tubal abortion, although unruptured tubal pregnancies carry a more favorable prognosis for future fertility than do ruptured tubal pregnancies. Fimbrial evacuation, a conservative technique, is one of the least used intervention methods, but the data about later complications are controversial. BhCG levels may serve to determine whether fimbrial evacuation should be used. More experience and proper patient selection is needed before more definite recommendations can be made.
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PMID:Tubal abortion and infundibular ectopic pregnancy. 358 54

The term "pregnancy interception" covers all fertility control methods that interfere with implantation of the fertilized egg, either by inhibiting its transport or implantation or by eliminating the already implanted blastocyst. A few researchers beginning in 1960 used high doses of estrogen in the immediate postovulatory period to prevent implantation. It was discovered that administration had to occur soon after coitus to be effective. Estrogens were administered orally for 5 days beginning in the 72 hours following unprotected intercourse in the ovulatory phase. Secondary effects were common: vomiting in 40% of cases, menometrorrhagia in 30%, and almost constant breast discomfort. About 10% of pregnancies in case of failure of the method were ectopic. The mechanism of action is still not understood. A combined treatment of 50 mcg ethinyl estradiol and a 19-norsteroid progestin has been used since 1975. It must be administered in the 48 hours following coitus and repeated 12 hours later. The duration of treatment and quantity of hormones are significantly reduced, but the secondary effects are similar to those of estrogens used alone, and the failure rate is 2%. Some progestins can also be used alone. IUD insertion up to 7 days after the unprotected intercourse has a contragestive effect, but the risk of infection is considerable and 3% of patients develop endometritis. The risk of secondary sterility discourages use of the method, especially in nulliparas. The prostaglandins E and F are effective in early pregnancy termination, but their side effects considerably limit their use. The average duration of bleeding is acceptable, but prostaglandins cause very painful uterine contractions in 30-40% of cases. Gastrointestinal secondary effects often require termination of treatment. The recent synthesis and use of the antiprogesterone compound RU-486 offers real promise for a widely usable contragestive method. Progesterone is indispensable for the continuation of pregnancy, and inhibiting its action on the endometrium interrupts pregnancy. An antiprogesterone acts by competing directly with progesterone at the target cells. The antiprogesterone RU-486 also has dose-dependent luteolytic and antigonadotropic effects whose mechanisms are not completely understood. Clinical trials have proven the innocuity of RU-486, and its efficacy of about 90% will undoubtedly be improved. Interruption of early pregnancy is a major indication for RU-486. The duration of the pregnancy appears to be the determining factor in the percentage of success, but most researchers have had failure rates of 15% even in pregnancies of less than 5 weeks. Possible heavy bleeding or failure in case of ectopic pregnancy indicate the need for medical surveillance. A different route of administration and combination with a small dose of prostaglandin would undoubtedly raise the success rate. RU-486 may have more promise as a post-coital agent, and may potentially be the basis for development of a once-a-month pill.
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PMID:[Contragestion]. 365 95

Postcoital contraceptives, the so-called "morning after pill," are agents used as emergency treatment to prevent pregnancy after unprotected intercourse or contraceptive accidents. In the 1960s and early 1970s high doses of estrogens were used in 5-day courses such as diethylstilbestrol 25-50 mg a day or ethinyl estradiol 0.5-5 mg a day begun within 72 hours after coitus. Although effective, a considerable drawback of the associated nausea and vomiting as well as an increased risk of menstrual disturbance during the treatment cycle. Norgestrel alone in various dosages has been used postcoitally. Quingestanol has been used as a continuing postcoital agent in Latin America but proved unacceptable owing to nausea and irregular bleeding. In China "visiting pills" have been devised containing anordrin. In the West regimens of this sort have been superseded by the Yuzpe treatment of 100 mcg ethinylestradiol and 0.5 mg levonorgestrel initially, repeated after precisely 12 hours. The treatment must be initiated within 72 hours of exposure. Postcoital contraceptives act by combinations of mechanisms--the function of the corpus luteum is disrupted, tubal motility may be affected, and changes in endometrial biochemistry prevent ovoimplantation. In a multicenter trial involving 602 women Yuzpe reported a pregnancy rate of 1.6%. Other workers show comparable figures of 0-3%. The primary side effects of the current hormonal method are nausea, which occurs in 61% of cases, and vomiting, 20% of cases. Both are mild and of short duration. All postcoital methods carry a risk of ectopic pregnancy should the treatment fail. 3 ectopic pregnancies were recorded with diethylstilbestrol and 1 recently with the Yuzpe regimen. There have been no reports of thromboembolic complications. If a hormonal form of postcoital treatment fails, the theoretical possibility of the pregnancy being harmed cannot be ruled out. The patient needs to be counseled about this, and careful records should be kept. Also important is the taking of an accurate menstrual and coital history to exclude exposures earlier in the menstrual cycle. Lippes and coworkers showed the efficacy of copper IUDs as postcoital agents. These can be used up to 5 days from intercourse. An IUD is preferred if hormones are contraindictated, if exposure was more than 72 hours beforehand, if the woman desires the most effective method, and if she wants the IUD for longterm contraception. Postcoital contraception, however defined, raises ethical questions. Postcoital methods could be classed as contraceptive rather than abortive within the maximum period (defined by medical scientific consensus) that may elapse between intercourse and nidation.
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PMID:Postcoital contraception. 613 82

Although no postcoital method has been developed for safe and effective regular use, postcoital contraception is being offered in Canada and Western Europe on an emergency basis to people who experience such problems as a burst condom. It is little known in the US, however. The 1st commercial version of a postcoital method recently became available to women in England. A former postcoital contraceptive was diethylstilbestrol (DES) which has been linked to cancer in the daughters of women who had taken the drug to prevent miscarriage. A new postcoital contraceptive regime was developed by Albert Yuzpe and consists of 4 ordinary contraceptive pills combining estrogen and progestin to be taken over a 12-hour period. In the US, this is the formulaion of birth control pill marketed under the trade name Ovral by Wyeth Laboratories. England and Germany are the only countries in which the Yuzpe method is officially approved for use as an emergency postocital contraceptive, but the method is used to some degree in most European countries, being well-known in France and Denmark. The most frequent side-effect reported by Yuzpe is vomiting experienced by 29% of women; another 22% felt nauseated. Other side effects, e.g. headache, were infrequent. The findings of the Pregnancy Advisory Service and the Brook Advisory Centre in Britain are reported. Overall very few side effects were found. Postcoital contraceptive treatment may cause the length of the cycle in which it occurs to be irregular. Treatment before day 15 has been found to shorten the cycle, whereas treatment after day 15 lengthens it. The majority of women who become pregnant due to treatment failure tend to seek an abortion. Ectopic pregnancy incidence may also be a result of treatment failure. In 1981, the International Planned Parenthood Federation (IPPF) issued a statement endorsing the use of postcoital contraceptives. Reasons for using them include rape, problems with barrier methods, ineffective use of the pill and IUD expulsion. No drug company in the US has expressed interest in getting FDA approval to market a postcoital contraceptive, partly because its usage might not be widespread. Opposition to approval from groups who believe life begins at conception and consequently that postcoital contraceptives are an abortifacient is expected.
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PMID:Contraception--the morning after. 651 38


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