Ectopic Pregnancy Barnhart, Kurt T
The New England journal of medicine,
07/2009, Letnik:
361, Številka:
4
Journal Article
Recenzirano
A healthy 29-year-old woman who has been trying to conceive presents with vaginal spotting for the past 5 days and intermittent crampy abdominal pain in her left lower quadrant for the past 3 days. ...Her last menstrual period was 6 weeks and 2 days before presentation. She has had a spontaneous vaginal delivery and an anembryonic gestation treated by dilation and curettage. How should this patient be evaluated and treated?
A healthy 29-year-old woman who has been trying to conceive presents with vaginal spotting for the past 5 days and intermittent crampy abdominal pain. Her last menstrual period was 6 weeks and 2 days before presentation. How should this patient be evaluated and treated?
Foreword
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.
Stage
A healthy 29-year-old woman who has been trying to conceive presents with vaginal spotting for the past 5 days and intermittent crampy abdominal pain in her left lower quadrant for the past 3 days. Although she normally has regular menstrual cycles, her last menstrual period was 6 weeks and 2 days before presentation. She has had a spontaneous vaginal delivery and an anembryonic gestation treated by dilation and curettage. How should this patient be evaluated and treated?
The Clinical Problem
Miscarriage is the most common complication of early pregnancy and occurs in 15 to 20% of clinically evident pregnancies. . . .
The rationale to freeze all embryos to avoid transfer into a supraphysiologic environment to improve safety and efficacy is compelling, but not yet proven. How do we decide?
Objective To assess the impact of endometriosis, alone or in combination with other infertility diagnoses, on IVF outcomes. Design Population-based retrospective cohort study of cycles from the ...Society for Assisted Reproductive Technology Clinic Outcome Reporting System database. Setting Not applicable. Patient(s) A total of 347,185 autologous fresh and frozen assisted reproductive technology cycles from the period 2008–2010. Intervention(s) None. Main Outcome Measure(s) Oocyte yield, implantation rate, live birth rate. Result(s) Although cycles of patients with endometriosis constituted 11% of the study sample, the majority (64%) reported a concomitant diagnosis, with male factor (42%), tubal factor (29%), and diminished ovarian reserve (22%) being the most common. Endometriosis, when isolated or with concomitant diagnoses, was associated with lower oocyte yield compared with those with unexplained infertility, tubal factor, and all other infertility diagnoses combined. Women with isolated endometriosis had similar or higher live birth rates compared with those in other diagnostic groups. However, women with endometriosis with concomitant diagnoses had lower implantation rates and live birth rates compared with unexplained infertility, tubal factor, and all other diagnostic groups. Conclusion(s) Endometriosis is associated with lower oocyte yield, lower implantation rates, and lower pregnancy rates after IVF. However, the association of endometriosis and IVF outcomes is confounded by other infertility diagnoses. Endometriosis, when associated with other alterations in the reproductive tract, has the lowest chance of live birth. In contrast, for the minority of women who have endometriosis in isolation, the live birth rate is similar or slightly higher compared with other infertility diagnoses.
In this randomized trial, treatment with mifepristone before the use of misoprostol resulted in a higher rate of successful management of first-trimester pregnancy loss than treatment with ...misoprostol alone.
Most IVF-conceived children are healthy, but IVF has also been associated with adverse obstetric and perinatal outcomes as well as congenital anomalies. There is also literature suggesting an ...association between IVF and neurodevelopmental disorders as well as potentially long-term metabolic outcomes. The main driver for adverse outcomes is the higher risk of multiple gestations in IVF, but as the field moves toward single embryo transfer, the rate of multiple gestations is decreasing. Studies have shown that singleton IVF pregnancies still have a higher incidence of adverse outcomes compared to unassisted singleton pregnancies. Infertility itself may be an independent risk factor. Animal models suggest that epigenetic changes in genes involved in growth and development are altered in IVF during the hormonal stimulation and embryo culture. Further animal research and prospective human data are needed to elucidate the mechanisms by which IVF may contribute to adverse outcomes and to decrease risks.
Well-designed and -conducted clinical trials are needed to further advance the field for reproductive medicine. However, current reporting of outcomes of trials is ambiguous and disparate. In this ...review it is offered that the preferred outcome for clinical trials in reproductive medicine should be live birth. Multiple births should be listed, and it should be specified whether this is multiple births per couple or multiple births per conception. The unit of measure should be women (or couples) and not cycles. The duration of exposure should also be clearly identified (i.e., treatment was one cycle, a prespecified number of cycles, or a period of time). Pregnancy loss should be specified, and the denominator should be those who conceived. Although live birth is the primary outcome, complications should be defined and reported, including multiple births and other objective markers, such as preterm delivery, small-for-gestational age, or stillbirth.
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