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Problems in the first trimester of pregnancy frequently occur. - Examples are miscarriage, ectopic pregnancy and recurrent miscarriage.- In Dutch hospitals there is a growing interest in the setting up of 'early pregnancy units' (EPUs). - The aim of these EPUs is to improve the quality of care for women with early pregnancy problems by centralising the care and knowledge available.- This centralisation could prevent over- and underdiagnosis and over- and undertreatment. - Moreover, EPUs could improve the logistics of clinical research. - The potential effectiveness of these units in the Netherlands still needs to be investigated

Letter to the editor

Three women, aged 21, 28 and 37 years, respectively, were diagnosed with interstitial pregnancies. The first patient presented with lateral abdominal pain, the second patient was asymptomatic and consulted the physician for a routine first trimester scan and the third patient had painless vaginal bleeding in the first trimester. Each was treated with systemic methotrexate in a multiple dose regimen, which was successful in the latter two patients. The first patient was discharged in good condition after her last methotrexate injection, but developed severe abdominal pain and collapsed at home after the interstitial pregnancy had ruptured. She underwent surgery and recovered. Today, the incidence of ectopic pregnancy in the Netherlands is around 8 per 1000 live births. Interstitial pregnancies, which nidate in the portion of the fallopian tube embedded in the uterine wall, account for 2-3% of all ectopic pregnancies. A urinary pregnancy test should be performed for any fertile woman with abdominal pain or abnormal vaginal bleeding. If the result is positive, the patient should be referred to a gynaecologist for transvaginal ultrasound to exclude ectopic pregnancy. In case of a pregnancy of unknown location, one should search for specific ultrasound markers of non-tubal ectopic pregnancy and assess serum human chorionic gonadotropin (HCG). Interstitial ectopic pregnancy should be considered if the serum HCG level is above 2000 U/l

A 36-year-old woman, who had given birth once before, had an eclamptic epileptic seizure eight days after caesarean delivery of healthy premature twins. Severe headache and loss of vision, leading to blindness, had not been recognised as prodromal signs by the healthcare professionals involved. Thereafter, she suffered a generalised epileptic seizure with tongue bite. She recovered fully after treatment with magnesium sulphate and nifedipine. Eclampsia is a severe condition with high rates of maternal complications, such as abruptio placentae, disseminated intravascular coagulation, neurological problems, pulmonary oedema, acute renal insufficiency and even death. Recognition of prodromal symptoms like headache, visual disturbances and upper abdominal pain is of the utmost importance. Magnesium sulphate intravenously is the treatment of choice. About 25% of the cases of postpartum eclampsia develop 2-28 days after delivery. A history of pre-eclampsia before or during the delivery is often absent. There is a relative increase in the incidence of late postpartum eclampsia, possibly because of misinterpretation ofprodromal symptoms, as illustrated by this case report. Every physician should be able to recognise the symptoms of pre-eclampsia and be aware of the possible consequences

BACKGROUND: The diagnosis of ectopic pregnancy can now often be made by non-invasive methods due to sensitive pregnancy tests (in urine and serum) and high resolution transvaginal sonography, which have been integrated in diagnostic algorithms. These algorithms, in combination with the increased awareness and knowledge of risk factors among both clinicians and patients, have enabled an early and accurate diagnosis of ectopic pregnancy. As a consequence, the clinical presentation of ectopic pregnancy has changed from a life threatening disease to a more benign condition. This in turn has resulted in major changes in the options available for therapeutic management. Many treatment options are now available to the clinician in the treatment of tubal pregnancy: surgical treatment, which can be performed radically or conservatively, either laparoscopically or by an open surgical procedure; medical treatment, with a variety of drugs, that can be administered systemically and/or locally by different routes (transvaginally under sonographic guidance or under laparoscopic guidance); expectant management. The choice of a treatment modality should be based on short-term outcome measures (primary treatment success and reinterventions for clinical symptoms or persistent trophoblast) and on long-term outcome measures (tubal patency and future fertility). OBJECTIVES: In the treatment of tubal pregnancy various types of treatments are available: surgical treatment, medical treatment and expectant management. In this review the effects of various treatments are summarized in terms of treatment success, need for reinterventions, tubal patency and future fertility. SEARCH STRATEGY: The Cochrane Menstrual Disorders and Subfertility Group trials register and MEDLINE were searched. SELECTION CRITERIA: Randomized controlled trials comparing treatments in women with ectopic pregnancy. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data extracted independently by two reviewers. Differences were resolved by discussion with all reviewers. MAIN RESULTS: Laparoscopic conservative surgery is significantly less successful than the open surgical approach in the elimination of tubal pregnancy due to a higher persistent trophoblast rate of laparoscopic surgery. Long term follow-up shows similar tubal patency rates, whereas the number of subsequent intrauterine pregnancies is comparable, and the number of repeat ectopic pregnancies lower, although these differences are not statistically significant. The laparoscopic approach is less costly as a result of significantly less blood loss and analgesic requirement, and a shorter duration of operation time, hospital stay, and convalescence time. Compared to laparoscopic conservative surgery (salpingostomy) local methotrexate is not a treatment option. Injection of this drug, both under laparoscopic guidance and under ultrasound guidance, is significantly less successful in the elimination of tubal pregnancy. Systemic methotrexate in a single dose intramuscular regimen is not effective enough in eliminating the tubal pregnancy compared to laparoscopic salpingostomy. This as a result of inadequately declining serum hCG concentrations after one single dose of methotrexate necessitating additional methotrexate injections or surgical interventions. If methotrexate primarily given in a multiple dose intramuscular regimen is compared with laparoscopic salpingostomy no large differences are found in medical outcomes, both short term and long term. However, this treatment regimen is associated with a greater impairment of health related quality of life and is more expensive, due to surgical interventions for clinical signs of tubal rupture, generating additional direct costs due to prolonged hospital stay. Furthermore, indirect costs due to productivity loss are higher. Only in patients with low initial serum hCG concentrations systemic methotrexate leads to costs savings compared to laparoscopic salpingostomy

OBJECTIVE: To analyze the impact of new diagnostic tools on the use of laparoscopy on patients with suspected ectopic pregnancy (EP). STUDY DESIGN: Analysis of 686 consecutive patients who underwent laparoscopy or laparotomy for suspected EP from 1983 to 1995 at the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. RESULTS: With the introduction of more sensitive urine pregnancy tests, the positive predictive value (PPV) of diagnostic management increased from 0.42 in 1983 to 0.91 in 1988. The introduction of transvaginal sonography improved this figure to 0.93 in 1989. More recently, a PPV of 0.95 was achieved by adding serum human chorionic gonadotropin measurements to the diagnostic workup. The sensitivity and specificity of this new strategy were 0.97 and 0.96. CONCLUSION: New diagnostic methods greatly reduced the need for laparoscopy to diagnose or rule out EP. The largest impact resulted from the introduction of better pregnancy tests. The effect of other sophisticated tools was less dramatic but eventually contributed to a near perfect noninvasive diagnostic management, thus opening new perspectives for nonoperative treatment modalities

OBJECTIVE. To inventory current policy in the diagnosis and treatment of ectopic pregnancy (EP) in the Netherlands. DESIGN. Questionnaire. SETTING. Academic Medical Centre, Amsterdam, the Netherlands. METHODS. A questionnaire was sent to all I30 departments of gynaecology in the Netherlands. RESULTS. The response rate was 94% (n = 122). Transvaginal ultrasonography was very widely used, whereas results of serum hCG measurements were only available within 24 h in 75% of the departments. Eighty-three per cent of the respondents screen for EP in high-risk patients. Laparoscopic surgery was used in 62% of the departments, open surgery in 9%, whereas in 28% the surgical technique depended upon the skills of the operating gynaecologist. If desire for pregnancy was present, 53% of the departments operated always conservatively, 2% always radically, whereas in 43% conservative surgery was performed only in case of a healthy ipsilateral tube. Methotrexate was used in 38% of the departments for persistent trophoblast, in 16% as primary treatment of interstitial pregnancies and in 13% as primary treatment for tubal pregnancy. CONCLUSION. Diagnostic strategies for EP in the Netherlands are homogeneous and in conformity with the state of the art in the literature. For treatment, laparoscopic techniques are widely used. In almost all departments, conservative surgery is the treatment of choice. Use of methotrexate is so far limited to treatment of persistent trophoblast after a failure of conservative surgery

Between July 1989 and December 1994, we performed a prospective study in 265 patients with suspected ectopic pregnancy to assess the value of expectant management in patients with negative transvaginal sonographic findings and low serum human chorionic gonadotropin (hCG) concentrations. All patients had serum hCG concentrations < 1500 IU/l. Eventually, ectopic pregnancy was diagnosed in 68 patients (25.6%), intrauterine pregnancy in 81 patients (30.6%) and trophoblast in regression in 116 patients (43.8%). Test results of our diagnostic strategy, that integrated the results of serial transvaginal sonography, serum hCG monitoring and expectant management, were good: sensitivity 90%, specificity 98%, likelihood ratio of a positive test result 45 and likelihood ratio of a negative test result 0.1. Expectant management in patients with suspected ectopic pregnancy and low serum hCG concentrations proved to be safe, and it enabled us to avoid untimely invasive interventions in patients with an early intrauterine pregnancy or with trophoblast in regression.

A well recognized hazard of conservative surgical treatment of tubal pregnancy is incomplete removal of trophoblastic tissue. Persistent trophoblast can be detected by postoperative serum human chorionic gonadotrophin (HCG) monitoring. The impact of various surgical techniques on the post-operative clearance of serum HCG was investigated in a retrospective study. The medical records of 97 patients treated surgically for tubal pregnancy in the Academic Medical Center of the University of Amsterdam, The Netherlands, between 1 January 1992 and 1 August 1994 were reviewed; 28 patients were treated by salpingostomy by laparoscopy, 16 by salpingostomy by open surgery and 53 by salpingectomy by either method. There was no difference in the post-operative clearance of serum HCG after successful conservative surgery compared to radical surgery. However, persistent trophoblast occurred in eight patients (29%) after laparoscopic salpingostomy and in only one patient (6.3%) who had a salpingostomy by open surgery (relative risk 4.57). Serum HCG clearance curves allow early identification of patients with persistent trophoblast after conservative surgical treatment. Moreover, monitoring of post-operative serum HCG until it becomes undetectable is mandatory in order to reveal late-onset types of persistent trophoblast

A 29 year-old nullipara with pain in the right upper abdomen, hypertension and proteinuria was admitted to hospital at a gestational age of slightly more than 32 weeks with a tentative diagnosis of preeclampsia. Eight hours after admission she died from acute pulmonary and cardiac arrest. Autopsy revealed acute haemorrhage in a phaeochromocytoma of the left adrenal gland