Establishing symptoms scores for ectopic pregnancy

A French collaborative study has been published in the journal “Academic Emergency Medicine”. The authors set out to develop a symptom score to predict ectopic pregnancy rupture. The abstract can be read at: http://www.ncbi.nlm.nih.gov/pubmed/22221975

They examined a number of different pain variables. However the most significant were: vomiting during pain, diffuse abdominal pain, pain lasting more than 30 minutes and “flashing” pain. The presence of one or more of these pain features gave a detection rate for rupture of 93%, a 44% specificity and a negative likelihood ration of  0.16. What this means is that most ectopic pregnancies have one or more of these pain features – but they are not very specific – in other words other conditions will also give rise to these symptoms. The absence of any of these factors usually (although not exclusively) – means rupture has not happened yet.

The paper is of interest as there has been a call to try to better understand the symptoms associated with ectopic pregnancy rupture. This paper is not the last word and patients should always err on the side of caution – but starting to understand the symptoms of ectopic pregnancy will hopefully lead to more robust advice so that women can identify dangerous symptoms when they occur.

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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Picture of the week

Mooring off Fishbourne during Cowes week on the Isle of Wight

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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Understanding how chlamydia impacts on the fallopian tube

There is a new paper in Fertility and Sterility (Fertil Steril. 2012 Aug 7. [Epub ahead of print) in that offers an excellent review of the mechanism of action of chlamydia on the Fallopian tube – what we know and where the gaps are in our knowledge. It is a review of the literature – so rather than summarise the paper here – we advise you to read it where is can be accessed on PUBmed.

The paper outlines how complex the mechanisms are that can lead to tubal infertility. It also describes how knockout mouse models can be used to study tubal function in the hope of better understanding how chlamydia impacts on tubal motility and implantation .

 

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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Fertility after an ectopic pregnancy

The two questions asked first by most women who have had an ectopic pregnancy are “how will this impact on my future fertility” and “what are the chances of me having an ectopic pregnancy in a future pregnancy”.

A new study published in the journal Fertility and Sterility from the research group in Clermont Ferrand in France gives good new information on these issues. They studied the outcome for 1064 women with an ectopic pregnancy diagnosed between 1992 and 2008 that had been entered into their registry. They found the cumulative pregnancy rate after 24 months ranged between 67 and 76% – with better outcomes when medical (methotrexate) or expectant management approaches were used. However other factors have an impact with reduced pregnancy rates in women over 35 years of age, with a history of sub fertility or tubal disease. The two year cumulative incidence of ectopic pregnancy recurrence was 19% irrespective of the treatment given for the original ectopic. The recurrence was highest after methotrexate – at 25% – although this was not statistically significantly higher than other treatments. There data also showed a 6.6% need for further treatment following conservative surgery and a need for further treatment of 24% after a single dose treatment with methotrexate. The most important take home message of the paper is that fertility after an ectopic pregnancy is higher in women managed conservatively – i.e. who has the ectopic removed from the tube with conservation of the tube at surgery or who are treated with methotrexate. This is particularly true in women who have a history of sub fertility. These observations are important – but like all studies must be interpreted with caution. Women who have a tube removed often have a larger ectopic pregnancy or have one with  higher hCG levels or have ruptured the tube. These are some of many factors that may alter the fertility outcome for any individual women. There are ongoing randomised studies looking at these issues. For the moment this large population study gives good information on which to base decisions.

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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Further evidence about the mechanism of miscarriage – failing to discriminate between healthy and unhealthy embryos

An important new paper has been published in relation to recurrent miscarriage (RM). Weimer et al have shown that there are differences in the migration patterns of endometrial stromal cells in women with and without a history of RM. In controls, the presence of a poor quality embryo was associated with inhibition of stromal migration. In women with a history of recurrent miscarriage this process seems to be deregulated and the endometrium is no longer able to discriminate between normal and abnormal embryos.

This is an important finding. It may add evidence to the view that miscarriage may be dies to a failure to recognise an abnormal embryo – in effect a failure of a natural quality control mechanism. Hence women with RM become pregnant very easily as all embryos implant – but then many pregnancies end in miscarriage due to the higher number of implanted abnormal embryos.

 

 

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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Fertility after drainage of a pelvic abscess

Seth Granberg is something of a legend in the world of gynaecological ultrasound. He dreamt up looking at the thickness of the lining of the uterus to predict cancer, developed morphological scoring for ovarian masses and published on many other subjects in the field. I first met Seth in about 1990 at a conference in San Antonio – and have since worked with him, lived in his house when I worked in Sweden and he was a guess at my wedding. So I was delighted to see him publish again.

Seth and his colleague Knut Gjelland have written about fertility after drainage of a pelvic abscess under ultrasound guidance. They have shown in a series of 100 cases – that for the women who wanted to become pregnant – the fertility rate was 53%.

Probably in most units the standard approach to a tubo-ovarian abscess is a laparoscopy (surgery under an anaesthetic) and treatment with intravenous antibiotics. Seth and Knut have shown that ultrasound guided aspiration is a viable alternative with comparable fertility rates to when laparoscopy is carried out.

In the paper the authors set out their view of how to manage an abscess. The advise early intervention in the form of transvaginal drainage under ultrasound guidance accompanied by intravenous antibiotics until the patients temperature has come down for 24 hours. Two weeks of oral antibiotics are then prescribed and in general the patient discharged from hospital within 3 days.

Currently prior to surgery most units will try and see if there is a response to 48 hours of intravenous antibiotics. Seth and Knut are suggesting this leads to an unnecessary delay and that drainage first is a better option.

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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Red wine, chocolate, add coffee to the list…

Now, my colleague and friend in Belgium has been telling me for some years that chocolate is good for me and I should eat more. I interpreted this as an attempt on his part to boost the Belgian export market in these times of austerity. He also is of the view that I write better after a glass of red wine, and gain a health benefit.

So today he has informed me the more coffee I drink the better, and referred me to a study in the esteemed New England Journal of Medicine published on May 17th ( N Engl J Med 2012;366:1891-904.0).  So it seems I can drink red wine (in moderation), eat dark chocolate AND have an expresso. The study by Freedman and colleagues looked at 229,119 men and 173,141 women – so these are serious numbers. They found an inverse relationship between coffee drinking and both total and case specific mortality. Furthermore the impact was greater the more coffee the subjects drank – up to 6 cups a day.

In terms of case specific mortality this included heart disease and stroke – but not cancer. There was no association between coffee drinking and cancer in women – and a possible association with men. Having said that there were some interesting characteristics of coffee drinker compared to non coffee drinkers. Coffee drinkers were more likely to drink alcohol more than three times a day, smoke and have a bad diet – and were generally less well educated or engage in physical activity. All a bit strange – but the numbers are certainly convincing.

So – I guess this paper gives reassurance to those of us who find full functionality in the morning prior to the habitual expresso rather testing. In my highly selected review of the literature (one paper) I am happy to believe this research because I like the outcome……….

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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And relax…

Really – the world is becoming a funny place.  A few years ago – the likes of the iphone and ipad were objects of pure fantasy, lusted after by gadget-mad men while watching the latest Bond film.  Are our lives enhanced, enlightened or dictated to by these extra-ordinary machines.  Before we had them, did we really look things up in books, wonder about answers to questions and come back to them later or did we simply move on and forget?  It seems you can find almost anything out and do practically anything with them.  I will leave you to make up your own mind, as  to whether they are smothering or simply amazing after discovering that you can buy an app for your iphone that reminds you to do your pelvic floor exercises, counts down the squeezes and rest periods for you,  and can be set to remind you to do them up to 5 times a day – quite extraordinary!!

Vicky

Vicky read general arts at university. She then worked briefly in retail before slipping, largely by accident into early years teaching. Her speciality is the glittery smear somewhere between a four year olds nose and ear. She lives in a menagerie of cats, dogs and children with a husband who can't quite believe how he ended up amongst the chaos.

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Can tiredness be a reason rather than an excuse….

The world we live in is so pampered, so privileged and so very harsh.  When did it become acceptable to view tiredness as a failure, a sign of weakness that one should just rise above?  We all race around as if on a hamster’s wheel and I really feel it is time we paused, just for asecond and listened to how we really felt.  Would productivity, creativity and enjoyment not be greatly enhanced by being just a little less stressed, pressed for time and quite simply tired.

I remember being pregnant for the first time, sitting on the tube in floods of tears.  I had been at work all day with the glitter and little people and I was exhausted.  Not just tired but boneshatteringly knackered.  My house was about 4 minutes from the tube but I just could not imagine how I was going to manage to walk that far.  People just stared at the crazy lady on the tube – unfortunatley glitter in your hair and poster paint on your clothes does give the impression of being slightly odd at the best of times but that wasnt going to help get me home.  I couldnt face askinga taxi to take me to the end of the lane, so snivelled all the way home, but why couldn’t I just say – I am TIRED and pregnant, please help.   Perhaps we all should be a bit kinder to each other, and in return to ourselves.

 

 

 

 

Vicky

Vicky read general arts at university. She then worked briefly in retail before slipping, largely by accident into early years teaching. Her speciality is the glittery smear somewhere between a four year olds nose and ear. She lives in a menagerie of cats, dogs and children with a husband who can't quite believe how he ended up amongst the chaos.

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Epilepsy in pregnancy – sodium valproate safety

Epilepsy is a problem in pregnancy although in general women will not see an increase in seizure frequency. Looking at the literature the obstetric implications are not as clear-cut as one might think. However in general it has been thought the risk to the fetus of uncontrolled seizures is greater than any risk from therapy. So most women are advised to carry on with treatment and to be carefully monitored as pregnancy may alter the pharmacological behaviour of any drugs that are given.

In the Mail online today the issue of birth defects and Sodium Valproate is raised. The dangers of this drug in pregnancy are well described and it is sad to read that it appears many babies each year are affected. In some instances the mother may have realised quite late on that she was pregnant – but for a planned pregnancy this should be avoidable. Usually monotherapy in the lowest dose to control seizures is advised in pregnancy – and Sodium Valproate avoided if at all possible. However any change in therapy from Valproate needs to be completed before conception – so this needs planning. Doses of more than 1000 mg per day are more likely to be a problem so attempts to reduce the dose to below this level will help reduce the risk of abnormality.

What does Sodium Valproate cause in the fetus? Unfortunately the problems are well enough described to give rise to the term “Fetal Valproate Syndrome”. Most common are variations of spina bifida (so if found to be on valproate women are given larger doses of folic acid), cleft lip/palate and a variety of limb problems. There are a large number of more rare complications that include brain, eye and respiratory tract abnormalities. Later children with valproate syndrome may have developmental delay and behavioural problems. I was taught these associations years ago – so there is no real excuse for someone not knowing about this problem now.

No anti-epileptic drug can be considered absolutely safe in pregnancy. However with careful planning it should be possible to make pregnancy as safe as possible. The article in the Mail is a timely reminder of the problems associated with some drugs in pregnancy. Hopefully the article will reinforce the message both for women with epilepsy as well as the clinicians that look after them.

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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